The Last Psychiatrist: 1 In 5 Cars Has A Personality Disorder

I. The New York Times: "1 in 5 People Has A Personality Disorder"

Almost one in five young American adults has a personality disorder that interferes with everyday life, and even more abuse alcohol or drugs, researchers reported Monday in the most extensive study of its kind.

And the article then becomes a list of every cliche and conflation possible. Though the article is about personality disorders, they then lament how common "mental problems" in college are, and the need for further treatment. One psychiatrist found the "widespread lack of treatment worrisome... it should alert not only ''students and parents, but also deans and people who run college mental health services about the need to extend access to treatment.''

Here is awesomeness:

Dr. Sharon Hirsch, a University of Chicago psychiatrist not involved in the study, praised it for raising awareness about the problem and the high numbers of affected people who don't get help.
Imagine if more than 75 percent of diabetic college students didn't get treatment, Hirsch said. ''Just think about what would be happening on our college campuses.''

Are we still talking about personality disorders?

It has the obligatory references to the Virginia Tech and other shootings. I seem to remember everyone's insistence that those were not due to personality disorders?

Well, I can see that the the current crop of adults, age 35-60, I so admire for leading our country into moral, economic, and intellectual greatness, have accurately identified one of the most pressing problems today. Nothing worse than an alcohol abusing, personality disordered college kid. Exactly what Allan Bloom would have thought, or, more accurately, exactly what they think Allan Bloom would have thought, as they can't be bothered to find out.

II.

The NYT is a blog pretending to be a newspaper. It's for adults, or people who want to pretend they're adults, who remember as kids that reading the Times meant something that they'd now like to apply to themselves. Now it's Bandwagon of the Month reporting: anyone see any global warming articles recently? Bush is suppressing them, I guess.

So the problems it describes must always be of the form: "the other guys who are not you are bad." That's widely perceived as liberal bias, though that's not accurate. It's "not you" bias. The online readership is 37 years old, print 42-- this is the demographic that says, 'College kids are weak and pampered, if I could only go back to college and do it all over again..." What? Get a physics degree, or date sorority girls? Or both?

III.

The article's conflation of "personality disorders" with every other kind of mental illness is a hint that an agenda is lurking. That a popular press article would even bring them up-- previously, everything was bipolar or schizophrenia and not personality disorders (think Virginia Tech)-- means that an agenda is lurking.

That the actual Archives of General Psychiatry study, from which this "1 in 5 Young Adults Has A Personlaity Disorder" news article is based, the one--

Results Almost half of college-aged individuals had apsychiatric disorder in the past year. The overall rate of psychiatricdisorders was not different between college-attending individualsand their non-college-attending peers. The unadjustedrisk of alcohol use disorders was significantly greater forcollege students than for their non-college-attendingpeers (odds ratio = 1.25) although not after adjusting for background sociodemographiccharacteristics. College students were significantly lesslikely (unadjusted and adjusted) to have a diagnosis of druguse disorder or nicotine dependence... than their non-college-attending peers. Bipolar disorderwas less common in individuals attending college. College studentswere significantly less likely to receive past-year treatmentfor alcohol or drug use disorders than their non-college-attendingpeers.

--in which the finding of personality disorder does not even merit a mention in the abstract, so insignificant was that finding to the study itself--

all that means an agenda lurking. You're not being given information, you're being given a worldview. Eat it.

IV.

But let's take it at face value-- 1 in 5 kids 18-21 have a personality disorder.

What's surprising about that is how low it is, considering that many of these "disorders" are normal developmental stages. When your 17 year old stays out past midnight, doesn't call, and then has the nerve to get mad at you for being mad at him-- that may be a discipline problem, but it's not a personality disorder. I get that you're angry, I'm with you, but the solution isn't a psychiatrist. The solution is not to consider that the problem is pathological, but that it is the default behavior that you must help them change.

Given the move towards infantilizing kids, that personality "disorders" would linger a little past adolescence-- into the sheltered Quad of Prolonged Adolescence U-- is not surprising. What matters is not the availability of treatment, but whether these "disorders" can be expected to resolve themselves naturally as they age, find relationships, jobs, a stable identity. Of course they can. Or, more to the point: the bias should be that things are normal, not pathological.

V.

But let's take a philosophical approach. What does having a personality disorder even mean? Can an inanimate object have a personality? Apparently, yes.

In Human Nature: 40 people looked at pictures of cars and had to rate them against 19 traits (gender, maturity, submissiveness, etc.) The subjects consistently identified the same traits among the cars.

"The study confirmed with some rigor what many people have already felt -- that cars seem to have consistent personality traits associated with them"

Obviously, cars don't have personalities, they are inanimate. We attribute personalities to them. No one would dispute this. You might say the cars are designed to elicit certain feelings towards them-- fine-- but the cars themselves do not possess character attributes, they only possess appearances.

Yet in the study, the different subjects-- these are not all genetic clones, they've had different lives and experiences-- still rated the cars as having the same attributes. What does it mean, really mean, when everyone thinks a car is aggressive, or submissive, when it isn't? Think about that, long and hard.

We have an internal personality constructs which are completely invalid. That they are hard wired into us, that so many other things are hard wired into us, doesn't make them less invalid. An optical illusion is still an illusion. These are cars. Metal. Your mind is tricking you, on purpose. What you saw was wrong.

When you look into the abyss, the abyss looks also into you.

VI.

Surely I'm not saying personality disorders don't exist? Or that people don't have personalities? If you were the Last Man On Earth, you'd still have a personality, right?

Even when you're alone, there's still "another person" present-- that internal dialogue you have with yourself, as another person. You're never truly alone, even if sometimes you don't like the company. And I haven't even brought up one's interaction with God, as epistemiologically unfashionable as that is to talk about nowadays.

All that aside, personality is the interplay between your physical/biological/innate/whatever traits and your life as you experience it (books and movies count); the interaction between you and Others. As such, it can be drastically altered, both by you and by other people, by time and environment, on purpose and not on purpose.

VII.

The consistency in the ratings of personality was, the researchers found, related to the appearance of the car; how far apart the eye/headlights were, etc. In other words, the cars were judged by how they look. "What's inside" the car, how it behaved, wasn't even relevant.

If this is true, how hard will it be for a person to overcome the prejudice based on appearance? How much will they have to overcompensate to make up for it? How strongly will you believe the person is a smart/mature/aggressive/etc, no matter what he actually does? Keep in mind these subjects know what a car is, they know that the appearance of a car does not reflect how it performs, they know cars don't have personalities, and still they give it certain attributes. How different will that be in people?

How easy will it be to resist simply conforming to the way you are viewed? How hard will it be for one person to say NO to the world, and self-identify? To resist the negative and the positive perceptions of others, in favor of who he decides he wants to be?

Pretty darn near impossible, I should think.

VIII.

Back to the NYT. I'm sure I'll be disputed, but hear me out: we're entering the age of Keynesian Psychiatry, and the NYT can't contain its ejaculate.

It's an era where "free will" and the normal checks and balances of society and superego are considered ineffective. No one can be expected to resist the id, and we need our parents to help keep us in control, or bail us out, send us money, when we need it.

We have massive bailouts, where the solution to 30 years of prior deficit spending is-- sit down-- more deficit spending; when the solution to overconsumption and undersaving is-- even more consumption and less saving. Similarly, 30 years of maladaptive behaviors will be treated with-- different maladaptive behaviors.

It's not profits and growth, it's "fiscal stimulus" and "infrastructure development"-- in psychiatry this means less focus on treatment, less focus on "remission," and increased spending on detection, prevention, education-- you're already sick, you just don't know it. This dovetails nicely with the (temporary) death of Big Pharma, who won't be generating any new treatments any time soon. And if it's not obvious why early detection and education is bad: you don't get to decide what kind of detection or what kind of education. Psychiatry does.

So too will there be increased "services" for the "mentally ill"-- redefined as anyone at all who wants the benefits-- even if these services weaken society in the long run. Both are Ponzi schemes built to fix prior, failing Ponzi schemes. They'll fail, just in time for our kids to get drafted.

Just as you see a move towards more government regulation and control, so will you see psychiatry mirror this. Laws will be written and revised, focusing less on punishment while simultaneously emphasizing surveillance. For example: "taking cocaine is a disease, it shouldn't be punished, it should be treated. So let's have mandatory drug testing for everyone 14 and older, you know, for early intervention."

Psychiatry as an arm of social policy means we have accepted society's new mantra: please save me from myself.

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http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: 3 Important Things About The New Wikileaks Controversy

um, yeah, this is the best picture from 2007 we could find for today's Guardian

Last week, Frontline did a documentary on Wikileaks which blew my mind. In it I learned Bradley Manning is gay. And short. And nothing else. No wait, about ten minutes in I learned I hate Frontline.

bradley manning.jpg

enemies of the state

I didn't think anything could make me an Assange supporter, but it turns out that the enemy of my enemy is my friend. That's right, I'm Alone.

Assange wanted to leak to the NYT, Der Spiegel, and the Guardian. However, he wanted the NYT to publish first to avoid the U.S. charge that he was leaking info to foreigners, i.e. take advantage of the 1st Amendment. But the NYT wanted Wikileaks to publish first, so then it could simply report on what was leaked, rather than be a leak.

These are probably legitimate concerns except for the fact that Wikileaks and the NYT are having this discussion explicitly. I'm not a lawyer but isn't that racketeering? It is like a bunch of mob guys discussing who should be the one to do the hit based on their parole status. Assange:

There was collaboration from beginning to end in terms of timetabling, researching stories, talking about how to understand data, etc., etc., embargo dates, the works. [NYT editor] Keller has tried to say we were just the source; they were a passive recipient... in order to protect themselves from the Espionage Act they needed to be completely passive, or be presented as completely passive.
One man's collaboration is another man's conspiracy. So any collaboration between a journalist and a source, between one media organization and another media organization, can be viewed, the Attorney General Justice [sic] [Eric] Holder says, as a conspiracy that flows through.

Assange is diabolically clever, I wouldn't expect anything less from the self-aggrandizing Cobra Commander. He's made this "collaboration" the point. Since they collaborated, the NYT can't pretend they were passive recipients, so they must therefore defend the legitimacy of such collaborations in general.

He's holding the press to task: your job is to keep the government accountable.

But they're terrible at it, as evidenced by the fact that while they were "collaborating," while they had all this juicy info sitting in front of them, the story the Times chose to run was one about... Bradley Manning.

The New York Times must stand up, and it must hold the line of the traditional form of journalism, because if it is not protected, it will be the end of holding the national security sector to account!!!

===== ====== ===== The Last Psychiatrist: 3 Media Narratives About The Middle East You Should Defend Against

if you're watching it, it's for you
(that's why the signs are in English)

1. Youth In Revolt

Ha! That's hilarious. Wait-- you're serious? You know Jay-Z is 40, right?

According to Time, these are the guys who toppled Mubarak. That one guy in the back punched him and the girl poked him in the eyes. The guy in the back right ate the body.

The New Revolutionaries: a liberal, pro-democracy group of consumerists concerned equally with global warming and expressing themselves, discreetly lip-synching the words to Lose Yourself as they march on Freedom Square.

You'll have to excuse my cynicism: I've seen this exact same movie a lot of times, admittedly to a CCR soundtrack.

Of course the young(er) are looking for social changes and a better life. And I don't doubt that they at least believe themselves to be earnest. But the media narrative that it is they who are the force behind the acute changes is both wrong and manipulative.

It's manipulative because it is easy. We can understand that kids might not like the world as it is, and the youth certainly appear to have enough energy drink to march for a week straight or yell anti-Bush obscenities, so it is logical that they're the ones to focus on. It gets Time, et al, out of the hard work of trying to figure out why the revolution happened, happened now, and if it's a good thing or a bad thing. Even Obama's not sure how this plays out, so the more we hear about youthful idealism on the march, the less we have to worry that Israel doesn't first strike Iran, just in case.

Also, it's self-aggrandizing. This is the folks at Time saying, "hey, man, we get this hip generation." It makes them think they're young and in touch, ("they even figured out how to use the internet for something other than porn!") and I'd bet 10 piastres every guy working at Time thinks the girl in the bottom right would find them interesting.

The narrative is wrong, or at least woefully inadequate, because-- in the simplest terms possible-- the guys in the picture aren't the ones changing the world. I'm sure they'd have thought voting for Obama was going to bring change, too, but they'd have been way wrong about that as well.

Here are some sobering statistics for the Time readers. There are 80M people in Egypt, 10% unemployment and 40% in poverty, as defined as less than $2/day. About a third don't know how to read. None of those people are in the picture. None of those people want the same things as those in the picture. None of them will ever listen to those in the picture.

There may have been 100k students in that Square, but if their 50 year olds are anything like our 50 year olds, then their 50 year olds might actually find those students infuriatingly arrogant regardless of what side they're on.

The sad truth is revolutions start with the disenfranchised, get attributed to the idealism of "students" and "the youth," and are ultimately resolved by thugs or corporations. Sideways Glasses Guy is in for a jarring quarter-life lesson in economic history, and I'm guessing he's not going to pass.

1b. The Young Are Mad As Hell, And They're Not Going To Take It Anymore. Sorta.

In the next issue of Time after that one, I found this picture of the Wisconsin union protests (click to enlarge):

Some observations:

1. Look at the crowd in the background. They're all older people. But Time has put the young ones front and center.

2. They do not appear to be members of the teacher's union. Or particularly fond of teachers.

3. They are smiling.

They're not angry, they're not outraged, they're... socially conscious? I'd bet a lot of money those kids aren't there to support the unions, that's not exactly their fight, but that fight happens to have a common enemy (feel free to speculate who that common enemy might be.) This explains precisely what is wrong with so many fights and positions and ideals: they are not for something, but against something else.

"What's wrong with coming out in support?" Well, go ahead and ask Time: "what's wrong with putting them front and center?" Because if I was agnostic about unions, and interested in really deciding who I supported in this fight, one look at that picture guarantees I side with whoever they're yelling at. If you want to know exactly what is wrong with the "political discourse in America today," it's that we are trained to pick a side against something we hate.

So choose your "face of the revolution" carefully because if it's an emotional response you are trying to evoke, there may be some unintended consequences. That's what happened in the 60s, too-- Woodstock the revolution and you landslide in Richard Nixon with a victory margin 3 times higher than Obama's. Guess music can't change the world after all.

2. The Mad Dictator That Has To Go

Oh, he may be a nutjob, but once he's out-- what, exactly? He's not a lone nutjob. There was an entire government in place there and while they don't all have voluptuous nurses you can be damn sure they want voluptuous nurses, and if they can't get that they'll settle for all your money and your obedience.

It's a narrative that existed long before the nights of Saddam, get rid of the dictator and things will get better. Sometimes it works, sometimes it doesn't, and if your country has oil in it it usually doesn't.

yes, Mr. President, I'm going to get a haircut and try and ride this one out

Imagine you replaced George Bush with Obama, but kept Cheney and Rumsfeld, Wolfowitz, Pearle, Rice... Imagine you get rid of all the Congressmen, but kept all the lobbyists, all the civil service employees, intelligence services, all the guys previously on the take-- and the media infrastructure. "The media supports the people!" Oh, yes, that has long been my experience with media.

It's so easy to get distracted by the Evil Despot that we aren't horrified that Egypt's chaperons of ===== ====== ===== The Last Psychiatrist: 4 Easy Steps Towards Weight Loss That Aren't Drugs, Diets, Or Excersise

I can't tell you not to eat it, but I can tell you how

If you don't like boring science, just skip to section III for the answer.

I.

Type II diabetics- and everyone else-- have two problems with their diets. First, eating too many calories causes weight gain. Second, food (like carbs) that causes excessive or prolonged insulin secretion, while helpful in the immediate (it clears the sugar so you aren't hyperglycemic) over time leads to insulin tolerance and resistance.

Hence, low carb diets are favored for both weight loss and for keeping insulin levels low(er).

However, while carbs are potent stimulators of insulin, protein and fat contribute as well. For example, consider two meals each of 2000kJ and 40g of carbohydrate:

Meal 1: steak and potatoes

Meal 2: bread, peanut butter, and milk

Not only is the insulin secretion not the same, it isn't even close: Meal 1 induces only half the insulin response of meal 2.

An old study measured the insulin response to some foods, relative to white bread (=100.) It also measured glycemic score, (e.g. per 1000kJ of it, not per 100g of it.)

You can see that the insulin response is not always related to the glycemic score. For example, brown rice is "as bad" as white bread (same glycemic score), yet causes considerably less insulin secretion. If you're diabetic, you'd want to eat brown rice instead of white bread. Etc.

In a more recent study, the weighted average of the insulin scores in a mixed meal was the best predictor of actual insulin levels-- carbohydrate amounts and glycemic index were not. (Fat, however, was a predictor.)

Summary: same calories, same amount of carbohydrate can result in different insulin responses.

II. How much insulin do you really need?

If I give you 100g of oral glucose vs. 100g IV glucose, will the insulin response be the same? No-- the oral glucose causes 3 times more insulin to be secreted. Think about this.

The reason is that hormones GLP-1 and GIP are secreted by the intestine within 15 minutes of eating-- specifically, after the absorption of fat and glucose there-- and are responsible for (among other things) 50%-70% of the insulin response.

The amount of insulin secreted is determined not just by the glycemic load, but the rate at which it reaches the intestine, because that's where GLP-1 and GIP will be released-- the main drivers of insulin response.

rate of glucose.JPG

(From Aug 2009)

Notice that when the rate of infusion of is doubled (from 2 to 4kcal/min) the insulin must explode upwards to result in the same level of blood glucose. You don't want that: chronic high insulin leads to insulin tolerance and resistance.

But now imagine taking a fixed amount of glucose, and either:

closed symbols: big dump (3kcal/min for 15 min) followed by trickle (0.71kcal/min next 2 hours)
open symbols: constant rate (of 1kcal/min x 2 hours)

All that's different is how you "eat" the glucose. Look at the graph. Circles are diabetics, squares are normals:

fast vs. constant infusion.JPG

Observe that the blood sugar is higher if you ate the sugar faster. For that meal, you were exposed to higher blood sugar. And insulin, more pronounced in the normals. For about 30 minutes, the people with the quick appetite experienced almost twice the insulin.

So slowing the rate at which glucose/food gets to the intestine would result in lower insulin levels and lower blood glucose, without necessarily changing the calories. If that sounds weird to you, learn it in the reverse: speeding up the glucose to the intestine will increase the GIP and GLP-1 and insulin response.

Eating smaller meals and less sugar clearly will help. But I think you see where I'm going:

III. Small Changes That May Help More Than A Little

Obviously, changing what you eat and how much you eat is very important. But these suggestions are not about altering the content of your chosen meal.

They're going to seem obvious now, but you should do them anyway.

1. Eating the same amount of food but much more slowly.

Any association you make to the European meal is your own business. The science says cramming the food down your throat while driving to the prison camp is a very bad idea.

2. Same amount of food, but change the order of the food you are eating.

Eating the fat and protein portion of your meal before the carbohydrate will slow gastric emptying. (It may also make you feel full and you eat less.) Don't eat extra fat and protein-- just move the protein portion to the front.

What you should not do is crack open a soda or iced tea or juice before you eat. If you must drink soda, which you mustn't, do it at the end.

If you are including a salad in your meal, definitely eat that first. (Soup would be an even better idea.)

3. Get more sleep.

Growth hormone is released during slow wave sleep, especially around 4-5am. Cortisol is inhibited. Sleep deprivation reverses this.

Even if total sleep time is the same, suppressing SWS reduces glucose tolerance. So: no sleeping pills, and get the sleep apnea handled.

Prolonged partial sleep deprivation increases ghrelin (appetite stimulating) and decreased leptin (appetite suppressing.)

4. Put cinnamon on your meal.

A bit of a cheat, but...

3g of cinnamon added to rice pudding reduced insulin levels with no effect on blood glucose. How can the body get away with using less insulin to deal with the sugar? Apparently because a) it increased GIP (see above); b) it stimulated the insulin receptor, resulting in increased glucose uptake. It should be logical, therefore, that cinnamon could exert its effect even if given separately from the meal: a small study found that 5g of cinnamon even 12h before the meal helped reduce glucose responses.

===== ====== ===== The Last Psychiatrist: 4 Unintended Consequences of Seroquel's Adjunct to Antidepressants Indication

cutting edge research on this drug should be coming any day now

Part 3 here-- short refresher.

In 1998, I discover something is red. "It's red." Sweet.

In 2010, I discover that same thing is also hard. "It's hard." Nice.

The question is: what is its primary attribute? Is it a Red thing that's hard, or a Hard thing that's red?

II.

Imagine you did it the other way around: in 1998 you discover it is hard, then in 2010 it's found to be red. Does that change things? Is the primary attribute based on history, or something else?

"I guess it all depends on what you use it for." You guess?

III.

Seroquel is that thing, discovered first to be efficacious in schizophrenia (translation: "antipsychotic") and now found to be efficacious in depression ("antidepressant").

So is it an antipsychotic that treats depression, or an antidepressant that treats psychosis?

"I guess it all depends--" Shut it. Scientists are talking.

IV.

You might think it doesn't much matter what you call it but rather how you use it, but it matters. If you call it an antidepressant, regardless of mechanism of action, price, or data it gets slapped with a suicide warning. If you call it an antipsychotic you forever battle a diabetes warning regardless of the truth of it (see Geodon, Latuda.) And call it the wrong thing, or the right thing at the wrong time, and your company gets to pay $1B to the government.

Seroquel is a special case study in the semiotics of psychiatry, because much of the naming was intentional.

1. Excessively high dosing.

One can't fault the FDA for striking a balance between safety and efficacy. They voted nearly unanimously "Yes" on its monotherapy efficacy in GAD and MDD-- they agreed it worked; but they didn't want it being used as commonly as Prozac, so voted unanimously "No" on safety. So no monotherapy approval.

Recall that one of the monotherapy trials of Seroquel showed efficacy at 50mg. However, because the FDA chose to go with the adjunct indication for safety reasons, it can only approve the doses used in those adjunct trials: 150mg. Three times higher than the "minimally" efficacious dose in a monotherapy trial.

So in choosing an indication out of safety concerns, it tripled the doses used.

The reps are not allowed to suggest you use 50mg, or tell you that those studies exist; indeed, they aren't told about those studies themselves.

2. Reinforcement of an erroneous mechanism of action.

The FDA wants to "protect the public". They know docs will generalize the indication of one drug to others in the class. Hence, the FDA's and AZ's interests run in parallel: not all antipsychotics are antidepressants.

So AZ avoids all talk about mechanisms of action which are shared by all atypicals (dopamine or serotonin antagonism) and settles on a mechanism which is specific to
Seroquel-- the NET inhibition.

However, as I hope is clear, from part 3, the NET probably has nothing to do with it.

3. Reinforcement of the cult of polypharmacy.

It worked fine as monotherapy; but it's indicated as an add on to drugs (SSRIs/SNRIs) that failed for over 100 days at high doses.

If the combination works, what then? Was it the Seroquel alone that did it? Was it the SSRI just taking longer to kick in? Or some kind of synergy? The FDA answer is that since you don't know, you use both.

But you do know: Seroquel worked as monotherapy in at least two FDA trials. Given this, it would be most logical to taper off the SSRI after a while, because you don't know two drugs are better than one drug, but I can promise they are twice as toxic and twice as expensive. But you won't find that recommendation in the PI or any academic journal. The FDA is causing psychiatry to move backwards: more polypharmacy; less safety; greater costs.

4. Pharma/academic focus on "bipolar depression."

Seroquel isn't indicated as monotherapy for MDD, but it is indicated as monotherapy for bipolar depression. Fortunately, 1) bipolar depression looks exactly like major depression during the episode; 2) it's indicated at 300mg, so you can be guaranteed to get heavier.

From the company perspective, the obvious marketing strategy is to push for "awareness and detection of bipolar depression" (read: "recurrent major depression is probably bipolar disorder"), and "incentivize" the reps to have their scripts skew towards 300mg. Farewell, depression, again.

For example, if Seroquel is truly an "antidepressant" then the competition would be Prozac. But it isn't; it's Geodon. Reps aren't measured against SSRIs, only against atypicals, which, in theory, they're not really competing against.

VI. Should we worry about any of this?

Nope. Once Seroquel goes generic, the impact of all of this nonsense will be minimal. Then no one will care how you use it, at what dose; whether you use it monotherapy or in combination with nine other drugs none of which anyone cares about either. Do a Pubmed search on Zyprexa research in the last year. Anything?

Granted, there's probably patients who do care. But.

===== ====== ===== The Last Psychiatrist: 50% of American Kids Receive Food Stamps

Marx was right. America is finished.

I saw the news article late last night, then read the study in the Archives of Pediatric and Adolescent Medicine, and was blown away. The data were solid: simple enough, just ask people if they'd ever been on food stamps, and count them.

30 years of household interviews, 1968-1997.

By age 20, 50% of all kids will have used food stamps at one time.

For black kids, the figure is 90%.

40% of kids in married households will have touched food stamps; it's 91% of kids in unmarried households.

The good news is that only 19% will use them for more than 3 consecutive years, which, of course, is also the bad news.

I was all set to be terrified about America's future, until I read the accompanying editorial, which reminded me of something someone said:

The bottom line is that the current recession is likely to generatefor children in the United States the greatest level of materialdeprivation that we will see in our professional lifetimes.The recession is harming children by both reducing the earningpower of their parents and the capacity of the safety net torespond. However, it is also essential to recognize that childrenhave been made extremely vulnerable to this recession by a decades-longdeterioration in their social position.

That something was: what does the author want to be true?

II.

In this case, while the results are technically accurate, they don't mean what it looks like they mean, i.e. that we should dust off Oliver Twist for a glimpse into our future.

Although the Food Stamp Program described in the paper is separate from the Women-Infant-Children (WIC) program, it appears that the study conflates the two. It's not relevant to the outcome of the study, so I'll simply focus on the WIC to show you why the headline is alarmist and misleading.

First, in determining household income, only the legal family is counted. The income of unmarried couples, grandparents, etc is not counted. This is true, e.g., even if the boyfriend is the biological father and he lives there or gives money.

Second, even though cutoffs for income are written as annual figures (e.g. $22,050 for a family of 4 or "185% of federal income guidelines"), they don't look at the past year's income, they look at how much the household is making right now, and then extrapolated.

income determination.JPG

Don't be fooled by "rate" of income. If you just lost your job, your rate is zero; you are eligible. And the next "mandatory" review is every 6 months. See you then.

Third: No proof? No problem.

Fourth: and more relevant to food stamps, a person can receive income from exempted sources (there are many);

Fifth: unlike unemployment, in which you have to "show" you are looking for work, food stamps aren't tied to need, only to nominal income. If you choose not to work (or choose to do volunteer work) and thus have no income, you're eligible. I'm not accusing people of abusing the system, but it is evident that some people would make adjustments in their behavior if food stamps didn't exist, rather than be committed to growth retardation and scurvy.

III.

There's also a bit of crazy, crazy math in play.

Nevertheless, only approximately 60%of those who are eligible for the program actually participatein and receive food stamp benefits. Consequently, it couldbe argued that the number of food stamp recipients representsan undercount of the total number of households in need of foodassistance.

So... 90% of America is in need of food stamps?

IV.

You will notice that I haven't used this study to make any judgment on whether food stamps is a "good" or "bad" program, not because I don't have a... nuanced... opinion, but because the study can't be used that way. However, it will be/is used precisely in that way.

It's troubling that, as scientists, it never occurs to the authors to objectively speculate why these figures might be erroneously high; in fact, they assume that they are too small.

Studies like this one are op-eds with numbers. They promote the particular bias of the doctors (read: social policy analysts) writing it. If 50% of kids get food stamps, then food stamps are necessary, end of story-- that's the point of the study. No politician in his right mind would dare question the implementation of such a program, let alone the need. In other words, it's not the the actual data that compels social policy, but rather the ability to say, "doctors have determined that..."

The press report interviews the author, the author of the editorial, and James Weill, "president of Food Research and Action Center, a Washington-based advocacy group." Gee, I wonder what they're all going to say.

I've many times remarked that doctors spin data to subtly impart their particular bias. Sometimes, however, they just yell it at you. Here is the first sentence of the each paragraph of the editorial:

Clinicians always inherit the results of bad social policy.
Children are poor because their parents are poor, a fact thatties the well-being of children to the employment status ofyoung adults.
Children are particularly vulnerable to the current recessionowing to the longer-term crisis in the American family's abilityto provide for its children.
In meeting the basic needs of children, the only real alternativeto the family is the state, an alternative that is increasinglyincapable of meeting the growing need.

And goes on like this, until the last paragraph:

Children depend upon political proxies to advance their societalclaims.

Note that he sets up the government not outside a family helping it, but inside the family, as a proxy parent, able to pick up the slack. Since the government has money, it looks like this works, and it seems crazy to say you want them out ("are you saying you want the government to stop handing out food stamps?"

But the populace is being trained to see themselves not as solely responsible for their children, but as part of a larger network of interested parties. That may sound comforting, but it radically alters behavior. It reinforces your connection to the state, as opposed to fostering your independence from it; and you become willing/obligated to sacrifice more and more in defense of the bureaucracy.

===== ====== ===== The Last Psychiatrist: $51M Vioxx Verdict Overturned

Judge Fallon decides that the jury's $50M award is a bit much for a heart attack in which the guy is still alive and well. He leaves in place $1M punitive damage award. (The $50M was compensatory damage.)

I also refer you to the PointofLaw blog, in which is observed the inconsistency of the jury's verdict: no, they aren't strictly liable for failing to warn about and causing the MI; and yes, they were negligent in failing to warn and causing the MI. How can you be negligent if you weren't liable?

Liable=responsible

negligent= "careless in not fulfilling responsibility" (from law.com). There was a duty toward the person AND you didn't do what a reasonable person would have done AND what you did actually caused the damage

===== ====== ===== The Last Psychiatrist: 5 Signs Your Child Is a Psychopath, According To The NYT

HOLY MOTHER OF GOD, WTF

The New York Times Magazine has a story describing a 9 year old boy who has been diagnosed as a psychopath. "Oh my God, that was such a moving article." Shut it.

Strangely/not strangely, they spend very little time describing the kid's psychopathy, and a lot of time on describing everything else from which you are to infer his psychopathy. It's like badly written female erotica, which is exactly what the New York Times Magazine is, penis never goes in vagina, it's all innuendo and mood and words words words words...

Here are the 5 signs of a child's psychopathy, according to the New York Times.

1. Ethnicity

You know how at the beginning of these profiles they always write, "In order to protect the privacy of the subjects, the names have been changed"? They don't have that here. Instead, to protect their privacy, they use the real first names. And where they live. And the name of their doctor.

Why would they use the real names? Employers/suitors already look at your drunken bikini pics and judge you hopefully favorably, shouldn't this kid's story be a little better protected?

Maybe the real names are important: there's Anne, the mom. Boleyn? No. Oh. Michael's the psychopath. Myers?! No. Dammit. Dad is Miguel.... oh.

As there are 10 million psychopaths living within 60 blocks of the NYT offices and another 200 inside the NYT offices, it's odd they needed to travel all the way to Florida to interview one. Maybe this psychopath is really interesting? Nope. Kill anyone? Nope. Cosplays The Ring? Nope. Started a hedge fund? Nope. Weird. Long way to go for boring.

2. Feet

If this kid had a swastika carved in his forehead or a tooth ring you can bet they'd photograph it, privacy be damned. No such luck, Michael refuses to look disfigured or appear black. So instead of his face you're getting a picture of his feet. Yikes.

psychopath kids nyt feet.jpg

Feet? I suppose kids' feet are interesting to some readers (e.g. psychopaths) but there's probably another reason for the photo. "It shows he's standing separate from everyone." Yes, but you put him separate, right? To tell us that he's separate? You also told everyone to take off their shoes.

So other than obvious staging of this crime scene, the NYT wants you to know either a) they're gypsies; b) mom's got 3 tattoos on her feet. One's a star. Do you know what a star tattoo means? It means what you are about to read is her fault.

3. Hands:

psychopath kids NYT.jpg

Well, that could be a picture telling us he has reddish hair and no swastika on his forehead; or it could be a picture telling us his mom has a thumb ring and Lee Press On Nails.

"Hey, no one's saying she's a bad mother!" No. You're just saying it all makes sense.

4. This:

psychopath dragon nyt.jpg

This is a picture of a blue dragon breathing blue fire. If the TSA saw this laying on a flaming bag of plastic explosives they would all go on break, so compellingly normal and safe and ordinary this drawing is. It is so normal that I've given it to babies in the NICU for comfort. They giggle. Here, I made it more scary:

psycho dragon 2.jpg

and even now Downy wants to make it the new symbol of freshness. I don't know how the hell this implies Michael is a psychopath. Does the Times now include a blotter acid insert? Should I lick this?

5. Science:

The New York Times loves science, LOVES it, especially the kind with no numbers and frequent appeals to authority, especially ESPECIALLY if those authorities are from the cast of Freakonomics. Here are the seven most important sciences according to the NYT:

1. Sociology
2. Political science
4. Climate science
5. Science fiction

7. NPR

8. Law

So when you see this:

Michael was almost two standard deviations outside the normal range for callous-unemotional behavior

and

One study calculated the heritability of callous-unemotional traits at 80%

you can be sure they have no idea what it means and have no expectation their readers do either, which is why they wrote it like that, in those words. NB: "One study"= it must be true. The readers think of genes as cluster bombs, if the father drops it into the mother her vagina explodes with untoward consequences. If you try to explain gene expression and interaction they start to glaze over, and by the time you hit imprinting all they hear is the theme to Dancing With The Stars. Whenever you read the word "genetics" or "heritability" in the popular press as it relates to kids, it means one of two things:

a) It's not your fault.

b) it's your ex's fault.

To reinforce this to the target demo, the genetic link of psychopathy, in Michael's case, is through the hispanic guy.

BUT DOESN'T MICHAEL SOUND LIKE A PSYCHOPATH?

In fairness to the Times, I will admit they list, explicitly, several psychopathic behaviors that Michael exhibits:

he threatens his brother with a chair

he says he hates his brother

he watches Pokemon

he can go from perfectly calm to full rage, and then calm again

rages include punching toilets, though not people

his mom is exhausted

his dad is exhausted, but less so

he erases the dumb reporter's digital recorder

he goes to psychopath summer camp, and doesn't like it

Because these aren't terribly diagnostic by themselves, the article is quick to mention the horrendous accomplishments of other child psychopaths. One kid chopped up a cat's tail. Another kid named Jeffrey Bailey drowned a toddler in the pool just because he was curious. Therefore, Michael is crazy. "Dude, that makes no sense." Dude, I'm just telling you what the article says. "Some, including Michael, were actually worse; one had begun biting the counselors." Wait, what?

Is Michael a psychopath? I have no idea, but I do know that the purpose of the story isn't to describe psychopathy, but to entertain a demographic that has nothing else to do on Sundays now that Desperate Housewives has been canceled. Have you learned anything you didn't already know from this article? "Don't let Michael date my daughter." Check. "Or my son! You never know, it's wrong to assume!" Double check. And mate. And I'm moving.

Scroll through the 631 deranged comments in the article, the two themes are "they need to remove the kid from the home for the family's safety!" which is totally ok when it's suggested by a deranged Manhattanite with no understanding of who "they" is, but everyone gets all Founding Fathers when George Bush tries it. "What gives him the right?!" Duh, you did. The other popular theme is "My heart goes out to these parents, what they must be going through!" but you only ever say such things when you're not at risk; and since the article lets you know it only happens to certain kinds of other people, your patronizing condescension is encouraged. "It is terrible, isn't it, but I guess it's true that other people are different from me." I will observe that no one feels bad for Michael even though this is supposed to be genetic= "not your fault" and he hasn't actually hurt anyone, which is precisely the kind of psychopathic prejudice I expect from the NYT and its deranged readers. Does anyone have any other suggestions besides extraordinary rendition or military academy? No? Then shut it. The kid is nine. You derangetons are 40 and still shamelessly retain the fantasy that your decaying mind and body will someday pull something off, meanwhile you're wrapping up shooting on his movie before puberty even hits.

Of course there are 9 yo psychopaths and of course you intervene early if you feel something's amiss and maybe Michael after all is one; but they sure haven't made a great case for it or the predictions for his future which, of course, are only implied, but you know.

Here's one explicit prediction-- and it is the Hail Mary of psychiatric predictions, offered without the benefit of conclusive research but you meet me at the bus stop at 3:30 if you want to fight about it-- one of the most significant causes of psychopathy is being told, at age 9, that you are a psychopath, and that the New York Times Magazine wants to do a ten page story about you. Yeah. Oops.

---

http://twitter.com/thelastpsych --- live tweeting the butchery that is Fifty Shades Of Grey tonight (May 22) during the finale of Dancing With The Stars.

===== ====== ===== The Last Psychiatrist: 5 Things You Need To Understand About Wikileaks Before You Celebrate

this is wikileaks

1. Wikileaks has made the MSM even more powerful.

The most astonishing thing in those cables appears to be that humans often hide their true feelings; that, and the fact that we have nuclear weapons in the Netherlands. (Now it makes sense why so many Dutch donate to my site.)

The thing to observe, however, is that I know those things not because I read Wikileaks, but because I read the NYT. Wikileaks didn't make anything public, in the exact same way as releasing all the clinical trial data didn't make anything public. There's too much information, we have no strategy for approaching it, and what if we read something that violates our prejudices? Fortunately, the MSM knows what you'll want to hear.

This isn't a trivial point. When the MSM reports on what Wikileaks says, we might be skeptical of the MSM but Wikileaks becomes the authority. If Wikileaks/MSNBC says "Russia Says UK Interfered, " then it is a fact that the UK interfered, that's the starting point. But perhaps Russia is wrong or lying; and who knows if Wikileaks isn't lying? I'm supposed to trust Assange-- why? Blondes are more honest? (NOT MY FORENSIC EXPERIENCE.)

And once it's out, you can't unlearn it. Pakistani The News ran a story saying Wikileaked documents reveal the Indian government was covertly supplying Islamist militants in Pakistan and committing atrocities in Kashmir. Whether any of this is true or not I have no idea; but it's not true that it came from Wikileaks. "Well, ok, maybe that didn't come from Wikileaks, but it's still true."

2. This statement is factually false: "Assange wants to expose the lies and corruption of the U.S. government; and the byproduct will be that diplomacy will be much more difficult."

He's not doing it to give to uncover the lies and corruption of the of the U.S. Government-- that's the byproduct. That this will force institutions and departments to wall off and not communicate with one another-- that's the primary goal. That's why Assange doesn't care whether the cables are salacious or revealing, only that there be a lot of them, leaked slowly over time-- to make people too nervous to work. His goal isn't to tell you what's in the truck but to stop trucking. If people know their secrets might be leaked, they'll be reluctant to put their secrets in a truck. Eventually, they will simply stop trucking. When they stop trucking, they go out of business.

Will it work? I doubt it: individual human beings (today) assume they are able to control when and how other people perceive them, which is why even though everyone has cell phone cameras I still see people picking their nose, stealing, beating suspects and masturbating in public.

masturbating subway.jpg

Even if government employees have the discipline to refrain from using their work computer for personal use (remember Deutch?) they still frequently use their personal computer/email for "light" work ("I'm leaving for Kabul next week, so make sure Jessica doesn't cheat on me.") Bonus: now Google (aka WikiCache) has that information.

3. Wikileaks hasn't made leaking documents easier, it's made leaking documents popular.

There's always been a market for leaked documents-- provided they are worth the risk. But what Assange has done with Wikileaks, complete with a logo and website and a famous frontman, is brand the illegality. Only the dedicated whistleblower will risk prison over an anonymous leak. But how cool is it going to be for a budding narcissist to be a pseudo-anyonymous leak to Wikileaks? What gets leaked becomes much less important than being a leaker.

You think a hipster is going to leak to the NYT? They're closer to the government than their readers, dude. That would be like leaking your senator's emails to your congressman. How you gonna get laid doing that?

The problem is actually Assange, not Wikileaks. It's evident to me that he wanted to become famous, or martyred. This is a man who clings to secrecy so desperately that he has a myriad of cell phones at multiple undisclosed safehouses that he uses right after he gives an interview on CNN.

But by making himself and his site as important a news story as the content of the cables, it inspires others to do the same. Doing what you believe in is never as compelling as doing what's going to get you popular.

Already the WikiClones are gearing up, and so it will be a matter of personal branding whether you leak your headshot to CNN via Leftyleaks or Rightyleaks. And the more such sites pop up, the less anyone will believe anything they "leak," but who cares? Will anyone believe anything about America that comes from IndonesiaLeaks? Won't matter. These become opportunities to offer your own opinions. No one argues about primary sources anymore, we argue the spin about primary sources. Quoting Baudrillard: "Once the sign replaces reality, you're not going to need Wikileaks."

4. The answer to this question: Why is Assange/Wikileaks so popular?

Wikileaks is a symptom of a time looking for an antihero, someone outside the game with enough power to smash the establishment.

You don't care about the exposed secrets; you just want to see the smashing.

That's what forms the basis of our political beliefs: hate. I could at least listen to communism if it was truly about equally distributing the bananas. But is seems much more about hating people with the bananas. A social policy based on hate and resentment is going to get you blood in the streets and then an emperor. A short one.

Most of the desire to see Assange succeed is based on our own impotence. You can't effect any meaningful change in the system, let alone in your own life-- and yes, that order is correct-- and so you're hoping someone else punishes the system for being bigger than you. But meaningful change is done either incrementally, or in revolutions, and I am certain no one has the enthusiasm to riot. At all. You can't muster up civil disobedience, let alone civil unrest. So you hope Assange has the balls to do it. NB: sex charges.

It was the same with Obama. People expected of him, what? To radically alter the United States? He's an entirely competent President, he's doing a reasonable job even as I disagree with almost everything he is and does, but it was obvious to me and it should have been to everyone else that he wasn't Change, but More Of The Same And Less Of Everything.

Things would have been different (NB: not necessarily better) under McCain for the simple reason that Obama didn't have the technical skills necessary to effect a vision that was nebulous to begin with. (Historically, the phrase "surrounds himself with really smart people" is followed in two years by "has lost his vision and is in danger of having a failed presidency.") And when you're unsure on a ship you walk very slowly on the quarterdeck, and soon you don't care so much where it goes as long as you don't get blamed for sinking it. McCain knew how to navigate a ship. Again, I respect that you might not have wanted him as your captain; but the choice was between McCain's slow course to the Islands, or floating around in the Sargasso Sea for four years. America voted: lower the sails. So: Afghanistan, Iraq, Guantanamo, secrecy, extension of the tax cuts, identical immigration policy, government deficits, (soon to be) no change in healthcare...

I'm sorry, I hadn't noticed you were gone

Assange is a hero to everyone who feels the system doesn't care about them. But as I have indicated with references, graphs, and statistical models, the problem isn't the system, xxx xxxxxxx xx xxx.

Assange's popularity among Americans should be, but isn't, a prompt for self-reflection. "Why do I want this guy to succeed, again?"

5. The winner is Big Business, the loser is you.

Back to the trucking analogy. If the government can't control the cargo or the trucks, it will try to control the roads. Since it can't, it will get private sector industry to do so. Ten years ago internet regulation would have been impossible, but the corporations that could have stopped it-- e.g. Google-- now would love a way around the net neutrality they thought they wanted a decade ago. Bonus: if the government imposes the restrictions, Google et al can't be blamed for making money on it.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: 7 Things To Expect In Our Brave New World

Financial turmoil directed by CNBC; a U.S. Presidential election so important that they are running a guy no one really ever wanted vs. a guy no one's ever heard of in an election subtitled "More of The Same vs. Less Of Everything." May you live in interesting times.

Here are five other things you don't want that are coming:

1. The return of pubic hair and mustaches.

The good times go with no hair; the bad times go with more hair. I don't like it any more than you do, but we're about to be bombarded with Starsky and Hutch look-a-likes and the totally earnest use of the phrase "luxurious bush." I'm going to go throw up now.

2. Fashion trends:

2a. Dressing like elves.

As in the Hobbit, not Keebler. Brown boots, green leggings and oversized shirts/sweaters doubling as skirts.

2b. Hose.

Just as society finally recovered from the 50 year self-mutilation called pantyhose-- even the WSJ debated whether it was still required for the office-- it will soon be making a comeback. If anyone in the fashion industry is reading this, stop killing your children. No one should be wearing pantyhose unless they're about to rob a bank. Please, I beg you all, stop this.

3. Another terrorist attack: February 2009.

Maybe I'm cynical, but has anyone noticed recessions are ended by wars? And that the S&P 500 closed yesterday, October 7, 2008, at the same point it did ten years ago, October 7, 1998? Which was also the historical low of the LTCM disaster?

Most recently 1989 S&L bailout lead to Gulf War I; and the scary similarity between the S&P500 pre 9/11 and now:

which was cured by Gulf War 2 in 2003... Do we get another attack to bring us down, then a war at S&P 800? Early, to test a new President's resolve? Stay tuned. I hope President Obama is ready.

Of course, it could be domestic terrorism/riots/Presidential assassination attempt, which unfortunately seems likely as well.

4. Conspiracy Theories: Like the above! Many of you will not be old enough to remember how the Nasca Lines, Lost Civilizations, Cryptobiology, JFK and Egyptology are connected, but they most assuredly are, as Mr. Spock explained to us, in 168 episodes of shroomy genius. And Erich von Daniken wrote 20+ books while the economy was crippled with stagflation.

5. Wrestling. Pick any show that's been running from 1995 to now. So many of them have seen ratings trend lower, except the WWE (formerly WWF before the panda patrol got testy.)

There was a surge when The Rock and Stone Cold were on, but ignoring that period ratings have been stable for over a decade. And that doesn't account for growth in Europe.

As people lose their jobs and look for a choreographed release of their frustrations and prejudices, one might be tempted to smell what you know who is cooking. And the stock, also stable between 13-19 (now 15) now pays a 9.7% dividend. Take that Bank of America!

When your kid endows body parts with political significance and then tombstones his brother, you'll know I was right.

6. Mercantilism. Enough said.

7. Secular humanism. In case your last experience with it was high school, let me point out that this is a bad thing, not a good thing. Yes, it's wonderful to have an ethical system free of religious foundation and therefore premised in reason, or something, but what happens when the humanist's "reason" is in sharp contrast to the "reason" of the humanist with the tanks?

It also overlooks the historically indisputable point that human(ist)s like killing each other and themselves, and will do so with little provocation. Indeed, many actively seek out reasons to open fire. "We are no better than they are" (and why isn't that ever, "they are no better than we are?") is a popular refrain among those who haven't been on the wrong end of the not any worse they, but it makes choosing sides a lot more difficult when, well, you have to choose sides. And if the S&P500 chart is any indication, we're going to be needing to choose some sides pretty soon.

-----------

Did you know Julian Huxley, eugenecist and brother of the author Aldous, was once an American Humanist Association's "Humanist of The Year?" So were Kurt Vonnegut, Margaret Atwood, Benjamin Spock, Isaac Asimov, Betty Friedan and John Kenneth Galbraith. Do you see the connection? They're all science fiction writers.

===== ====== ===== The Last Psychiatrist: 8 Characteristics of Family Annihilators

guess why

The case of Hugh McFall (from the BBC):

[He] beat his wife and daughter to death with a rubber mallet before hanging himself...
Hugh McFall, 48, of Oswestry, Shropshire, was found hanged on 5 February, hours after wife Susan, 55, and Francesca, 18, were found dead.
An inquest heard how he left a note by his body saying "I hope I rot in hell".

Why did he do it? More specifically: why does the news report say he did it?

I.

No one is surprised when the news reports murders; they're interesting in a pornographic way. ("Now I have these feelings, whatever shall I do with them?")

But the murder is secondary to the report; the murder is an excuse to release an already worked out narrative. Murder suspects and victims become unpaid actors for a reality show CBS calls "The News."

An example from this week:

"Hundreds Attend Vigil for Slain Kansas Cheerleader."

When you click on the link, what do you want to see?

Here is a picture of a tiger and nitrogen while you consider your prejudices:

monkey and sky.jpg

Be honest: you want to see a picture of a cheerleader. You sure as hell don't want to see a picture of a vigil-- but "vigil" = "pics of her while alive." Also: "Kansas"= white, which means she's hot. Otherwise they wouldn't have used the word "Kansas," they would have used the word "Trenton."

And what kind of a guy would kill her? How about "Rocco?"

Three burly cops="violent predator." Do I need to tell you what his criminal history is? If I told you that Rocco has a history of burglary but no prior rapes or sex offenses, would that make you suspect him less? No, because we all understand how a cheerleader might end up dead. Well, how did you come to understand that?

GREAT BEND, Kan. -- A 14-year-old central Kansas girl whose charred remains were found at an asphalt plant last week was a vivacious teen who loved bright colors and preferred wearing flip flops over any other type of shoes, according to those who knew her.

Hmm. Doesn't really match the cheerleader type. In fact, this girl wasn't really a cheerleader-- she was going to be a cheerleader when she started 9th grade in the fall. She was also going to be in geometry class, but they left that out.

That he killed a cheerleader makes sense; but killing some random 8th grader-- was he a first time pedophile?-- makes less sense.

Calling her a cheerleader certainly draws in the viewers, but at a huge societal cost. Most of us learn about murder through the news, and empirical evidence (news stories) tell us they're right, so we adopt their narratives. Narratives aren't necessarily bad-- unless they're wrong. I'm not saying he did/didn't do it; I am saying that when you put "cheerleader" in the headline, I am surer that he did it in spite of my attempts at being objective. I'm surer because you're surer.

And narratives are hard to unlearn. Now that we know that she's an 8th grader and that he has no history of prior sex offenses, do we double back and give him the benefit of the doubt?

II.

Filicides, the killing of your kids, is no different.

There are broadly five types: altruistic, psychotic, unwanted child, accident by neglect, spousal revenge. Although filicide is perpetrated in equal numbers by mothers and fathers, spouse + kid murderers are overwhelmingly men.

That said, the media like to report on only three of these types of filicides: mothers who are psychotic (weak) ; women who are looking to get/please a new man (evil); and fathers committing "altruistic filicide" in which the father thinks he is sparing his family worse suffering by killing them (snapped).

The case of Hugh McFall (from the BBC):

A florist beat his wife and daughter to death with a rubber mallet before hanging himself amid fears he would lose a big customer, an inquest heard.
Hugh McFall, 48... was found hanged on 5 February, hours after wife Susan, 55, and Francesca, 18, were found dead.
An inquest heard how he left a note by his body saying "I hope I rot in hell".

We're about to get a standard altruistic murder story highlighting the role of the employment, which completely misses the important subtleties. Here are the more important ones, with some interventions.

1. He's not losing a job, he's losing his ability to keep up the lifestyle:

The self-employed flower salesman was facing accusations of invoice discrepancies from his main customer - which had suspended his contract - and feared a police investigation into his accounts... "His financial world had collapsed, his source of business income or at least 90 to 95% of it, had disappeared in a moment. Their lifestyle, as he knew it, would be over."

1b. The lifestyle often involves some kind of "soft" illegality (accounting irregularities, the use of drugs, etc). The news may cite jail as the main stressor; but the general fear is the irrreproducibility of the lifestyle (e.g. even if he doesn't go to jail, he'll never be able to make that kind of money again, legally.)

2. A sudden, temporary, but unshakable realization that there is no way out of this. "This is the end of me," "it's over," "I'm dead," etc.

Business associates told the hearing that Mr McFall had considered himself "finished" after a meeting about alleged invoice discrepancies the day before his death.

If you hear a man say, "I'm finished", believe it. Especially if it doesn't seem as bad as he thinks it is. It's his inability to see alternatives (which would require another person's perspective) that makes him dangerous.

3. While anyone can see how severe the problem is, no one else sees the problem as insurmountable-- except him. "Why didn't he just...?"

West Mercia Police said the case would probably not have ended up in court but an investigation would have been started if the owners of Stans Superstore had taken their concerns to police.

This is his inability to see things from another perspective except his own. What's obvious to you is not obvious to him, and opportunities to intervene can be missed if you think he "would have thought of that himself." Be concrete, be basic. "Look, are you a legal scholar now? Let's get a lawyer." A lawyer? Really? "Yeah-- I know a guy-- and let him tell you what he sees; if they can get OJ off, they can get you off. If nothing else, it's going to buy you some time..."

The longer he can experience his shame, the longer he will be able to live with his shame (or create a rationalization that will let himself live with it. The goal isn't to solve his problems, but delay him until he can think straight.

4. Media says family murders= financial problems, but the money is merely the cover for the real shame:

The coroner said Mr McFall's fears about his sexual health may have been "going through his mind" when he killed his family, as well as his business worries and concerns over his "social standing".

And from another article:

A computer expert and senior forensic investigator told the inquest he had examined two computers as part of the investigation, one from the McFall's home and the other from his business premises. [An investigator] said someone had been accessing pornography, escort and massage parlour sites and seeking advice for diagnosing HIV.

Illegal activity, affairs, drugs... the money is important because it hides those things, allows him to present himself as something he wants to be.

Sometimes the financial narrative is so compelling it seduces even experienced criminologists. Criminology professor David Wilson:

"They've previously had wealth, had possessions, they went on foreign holidays. The annihilator feels 'given that I can't give my family any of this any longer' as an act of almost mercy, as they would see it, 'I'll take their lives so as to prevent them having experiences of any hardship'."

Wrong, always. It is impossible to think your children are better off dead unless you are unable to see their perspective. If you asked them, what would they say? Why wouldn't you believe them? Why do you think you know better than they do?

They aren't better off dead; you're better off if they're dead. That's the secret that must be undone.

5. SHAME.

"I can't give them what they deserve" is a deflection from "I can't give them what they deserve." The panic is about them becoming aware of your failure.

[the criminologist] believes where they lived was a factor: "Oswestry is a face-to-face society. Those kinds of societies often provide a great deal of support, but if the wheel comes off in this type of society, then everybody knows your business... It's not like they are in a big city where they can simply disappear and become anonymous.

The same applies to honor killings.

The money is most often the final straw; without the money, you can't keep up the appearances...

Murders happen before the exposure, before "everyone finds out." Once they've found out, there is no reason for the murder. So either tell his family, or make him think you have. But then:

6. Sometimes he kills himself, and sometimes he doesn't.

He kills his family because he can't face them knowing. He kills himself because he can't face that they know.

The other reason for the suicide is the sheer number of people who are going to know-- can't kill 'em all.

The likelihood of suicide increases as guilt increases, and decreases the more you can be convinced other people won't know/won't care.

7. A very fine line: it was both spontaneous, and premeditated.

Two years ago another family murder took place near Hugh McFall's town, and McFall was horrified:

I remember Hugh saying 'How could you do that? How can it get so bad that you could do that to your family?... It just doesn't make sense, surely there's other ways out however bad things get?'"

And certainly he wasn't thinking about killing his family before the financial problems hit. But as soon as he decides he's "finished," he starts planning the murders-- weapons/tools obtained, the biggest threat is killed first (i.e. wife before kids), etc.

7. Get out of the house, or at least the bedroom.

75% occur in the home, usually in the bedroom. It is extremely unusual (6%) for the man to kill only the children and not the wife. Since the purpose of this is to avoid shame, leaving the wife alive would be contrary to the point.

If you're the wife, don't go home, especially if he says he'll kill the kids if you don't.

Tom recognized her instantly despite the red anonymity bar

It's not going to D2 receptors, because they're all already blocked with Risperdal. So it's just going to go around to other receptors-- H1, a1, M1, etc-- all of which have nothing to do with bipolar or psychosis. Issues of tolerability aside, mixing two antipychotics is no different than giving more of just one antipsychotic.

"Abiliquel"-- taking Abilify and adding Seroquel-- is sheer idiocy of such magnitude that even Eli Roth is repulsed. The first time someone told me what Abiliquel was, the room became filled with the sounds of six guys screaming in horrific pain, and that was because I was punching them in the testicles. Why not just give him Motrin + Advil? Oh: "But I use it cleverly: I give 15mg of Abilify and 25mg of Seroquel. See?" I see. I see that you're bleeding from the testicles. Guess why. You give 15mg Abilify-- that's acting as a D2 blocker. 25mg Seroquel isn't even a D2 blocker, it's an H1 blocker, you're paying for an antipsychotic and getting Benadryl. You say, "well, I know," (liar), "but I'm using the Abilify as an antipsychotic and Seroquel as a sedative." But, Gwyneth, you could have gotten the exact same effect by giving Abilify and Benadryl+trazodone-- which would be cheaper, and safer; or giving simply 500mg Seroquel alone, which would have gotten you both antipsychotic effect and sedative effect, thus reducing the cost by half, etc, etc. Remember that scene in the movie Hostel where Matthew McConaughey gets bitten by a radioactive lab rat and transforms into an immortal superhero?

Matthew McConaughey (Owen Wilson) proves there can be only one.

No? Do you know why? Because you knew better than to see that celluloid atrocity. How come you didn't know better than to prescribe two antipsychotics at once? You don't mix Zoloft and Paxil together, do you? Haldol and Prolixin? Seriously, do you just make crap up as you go along, or do you have pharmacological non-sequitors prepared in your Moleskine?

The same, by the way, goes for all you nutboxes who work in hospitals. If you have a patient on, say, 10,000mg of Seroquel, and he goes into an ER and gets indignant and flips a table over, and you inject him with 5mg of Haldol (90% blockade), you think that 10,000mg of Seroquel is doing him any good as an antipsychotic? I gots news for youse all: every time you prn (emergency dose) someone with Haldol, their brain is only on Haldol. Any other antipsychotic you give them that day is strictly a monetary gift to Big Pharma; you may as well PayPal them $180 and spare the patient the exposure.

On second thought, you may as well PayPal me.

-------------------

1. There may come a day where a drug is invented that works through some other mechanism, maybe glutamate, but as of right now, all the available antipsychotics work through D2 blockade. Everything else is irrelevant. Now, these other receptors might be relevant for other effects (reducing anxiety, antidepression, etc) but let's try to focus on the specific problem and not get all Andrew Weil here.

===== ====== ===== The Last Psychiatrist: Are People Attracted To Good Dancers?

Chris Rock: a father's only responsibility is to keep his daughter off the pole

"Study: Flamboyant male dancing attracts women best"

LONDON - John Travolta was onto something. Women are most attracted to male dancers who have big, flamboyant moves similar to the actor's trademark style, British scientists say in a new study.

Awesome, another "front page" science article that misses the point.

The researchers filmed some men dancing, and then CGI'd them into silhouette avatars which they forced sober women to watch.

dancing avatar.jpg

"There are lots of cues females use when choosing a mate, like a peacock puffing out its tail," [some evolutionary behaviorist guy] said. "Dancing for humans could signal whether a male is fit because it requires the expenditure of a lot of energy."

It could also signal you have to pee. On the one hand, the study itself gets it wrong; and on the other hand, the reporting gets it even more wrong. Two wrongs make a post.

II.

The actual study found that:

According to the women, the best dancers were those who had a wide range of dance moves and focused on the head, neck and torso [and not arm and leg movements]

Somehow this got translated to "women are attracted to good dancers" but it only says they liked that kind of dancing, it did not say the women thought those men were more attractive, especially since they weren't men but CGI humanicons with no visible external genitalia such as tattoos or Nautica T-shirts. Extending "I like his dancing" to "he's hot" is the sexual equivalent of extending "he has good penmanship" to "he writes like Balzac. I'm so looking him up on Facebook."

And you can't bring up examples like the professionals at Dancing With The Stars because they possess what's called a "confounding variable," namely that they are all extremely attractive CGI humanicons with prominently displayed external genitalia that I have never DVR-paused to get a good look at, even as I have never fast-forwarded through their ridiculous interpretations of the cha-cha to get to Brooke Burke.

Of course women will like good dancing more than bad dancing, but I am not sure that women are attracted to better dancers-- which is the only reason evolutionary psychologists would be interested in the question. If it doesn't lead to penetration, they don't want to hear about it. But here, "more attractive as a mate" does not logically follow from "better dancer." A Craig Ferguson joke: "A new study reports that women are attracted to better dancers. The ironic thing is that they're all gay."

(Thanks DL for the vid)

III.

But the more serious problem with the study this:

He and his colleagues think dance is an honest signal to women of the man's strength and health, just as it is in crabs and hummingbirds... It makes sense that women would care about men's ability to dance, says Helen Fisher, a biological anthropologist at Rutgers University in New Brunswick, New Jersey. "For millions of years, a man with well-coordinated movements of the head, neck, and trunk [which he used when throwing weapons] probably signaled his ability to provide"

This is completely crazy. She could have used that same explanation if flailing arm movements were what was more attractive, she just has to replace "head neck and trunk" with any body part that was preferred and she can win tenure. I also don't know if she's aware that the words "man" and "millions" and "throwing weapons" and "well-coordinated"have no business being in the same sentence, unless that sentence is the one I just wrote.

Consider also that this is dancing today, in western Earth. If this is supposed to be a generalizable observation about intraspecies attractiveness, how would we rate the hotness of the dances people did in the middle ages, the ones with the ribbons attached to poles? Wasn't Maypole dancing itself derived from a pagan fertility dance whose purpose was to get you knocked up?

If this study is valid at all, then it is only valid only for modern, culturally created attractiveness. It is identical to saying "women prefer men with body hair because it signals virility." When was this? The only people who find 1970s pornstars attractive are 1960s pornstars, and communists, which are the same thing.

Maybe somebody can explain to me how evolutionary psychology can make predictions on a non-evolutionary time scale without resorting to genes, which it can't do anyway because it doesn't know of any.

Besides: natural selection stopped being applicable to human beings the moment we allowed other people to tell us what is attractive to us.

--

Is the hourglass figure the ideal?

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Are Schools Breeding Narcissism?

Comedian Todd Barry:

The guitarist for Third Eye Blind was on MTV Cribs, showing off his house. He picks up a guitar and says, "this is my favorite guitar. With this guitar, the songs just write themselves." Yeah, sure. Blame the guitar.

"Warning over narcissistic pupils:"

The growing expectation placed on schools and parents to boost pupils' self-esteem is breeding a generation of narcissists, an expert has warned.

Dr Carol Craig said children were being over-praised and were developing an "all about me" mentality.

Dr Craig is chief executive of the "centre for confidence and well-being" in Scotland. What? What are you looking at?

She told head teachers the self-esteem agenda, imported from the United States, was a "a big fashionable idea" that had gone too far.

She said an obsession with boosting children's self-esteem was encouraging a narcissistic generation who focused on themselves and felt "entitled".

I wanted to investigate this further, so I went down to the local elementary school, I grabbed one of the Zach Effron looking bastards by the neck, and I shook him like a dog, I said, "listen you North Face wearing organ donor, why is self-esteem so important to you? Why do you have to feel good about yourself all the time? Huh? Huh?"

Well, Zach ran off, bawling, and then I realized: he's not the one who cares about self-esteem.

Right? The kids didn't sign up for the self-esteem classes because it was pass/fail and fit in 3rd period. Adults made a collective decision that this was going to be the core educational philosophy from which everything else would be derived. So? What did adults think was wrong with the way they were raised that they thought self-esteem was so important to teach their kids?

I agree with: schools shouldn't be in the psychology business; emphasis on "feelings" paradoxically (read: not paradoxically) increases the likelihood of depression and anxiety; the more schools dealt with emotional well-being, the less parents would take responsibility, etc.

But she misses the cause. She sees the teaching of self-esteem itself to be the source of the problem; but the real problem is the cultural mindset that thought up self-esteem training-- and a million other things. Even if we stopped promoting self-esteem in schools, the kids are still going to have to watch TV created by these same adults; learn about other cultures from them; learn how to manage money from them; learn that the worth of the individual from them; learn whether killing is right or wrong, and when, from them. Not directly from them, of course, which would actually be a dialogue worth trying out; but by osmosis, from living in the world that adults have created for themselves, that kids have no choice but to live in.

In short, they're still going to have to go home to their parents.

Here's an example. I'm down at the playground stalking pedophiles, and I observe that all of the kids are there with a parent, and most of them are with both of their parents. The parents are actively playing, too, they're not just sitting on the benches socializing.

Wow, I think, there are actually more parents than kids on this playground. My parents would never have played with me/us like that. If they actually came (they never would have) they would have sat on the benches. Socializing.

And then I observe that there are 15 or so adults, all crowded around on this playground; however, none of the parents are talking to each other, they are talking only to their kids.

But they are so physically close to each other that it is visibly weird that they are not talking to each other; they must each have made a conscious decision not to interact. And then, it hits me: the reason these parents are playing with their kids and not on the benches is in order not to interact with the other parents. They're using their kids as human shields. They don't know how to have a personal but not intimate interaction with another adult, they can't figure the boundaries. All they know is stranger, friend and sex. All they know are roles.

Self-esteem training is besides the point: how are kids going to not become narcissists when their parents train them on purpose to avoid meaningful interactions with strangers?

It boggles the mind how adults complain about how "kids today" are soft, or narcissistic, or impolite. What, is that due to sunspots? An oncogene? "Kids today" aren't any wussier than their parents are making them.

"Kids today are soft, when we were kids we didn't wear bike helmets..." But the kid isn't asking to wear the helmet, you're putting it on their head.

She said an obsession with boosting children's self-esteem was encouraging a narcissistic generation who focused on themselves and felt "entitled".

She means the kids; yet the focus on children's self-esteem is the mechanism by which the parents protect themselves. If my kid is happy, then I have a happy kid; I don't have to do anything. It's the parents who feel entitled- to having a happy kid.

"Narcissists make terrible relationship partners, parents and employees. It's not a positive characteristic..." she said.

Nice call. A generation too late, but nice call.

===== ====== ===== The Last Psychiatrist: Who Are Academics Writing For? (For Whom Are Academics Writing?)

Interesting study from Princeton psychologist Daniel Oppenheimer, called "Consequences of Erudite Vernacular Utilized Irrespective of Necessity:Problems With Using Long Words Needlessly." (I should mention I have not read, and can't find, an actual copy of this study.)

Took a selection of writing samples (grad school applications, sociology dissertations etc), and changed each of the words to more complex/longer synonyms. Then he gave these samples to 71 students and asked them to judge the intelligence of the authors. The more complex and flowery the language, the dumber the author was assumed to be.

Think about it...

From collision detection

===== ====== ===== The Last Psychiatrist: "Are there really so many people with such troubles in your country to make such medicine such an important matter?"

A reader writes:

"I'm from Europe, Romania...you speak about a medicine intended to declare/sell that medicine as "mood stabilizer"... However, are there really so many people with such troubles in your country to make such medicine such an important matter? I didn't think of America as being such a sad/depressed country and a medicine called "mood" something seems to me such a stretch..."

How I wish I had made this up. The email closes:

I'd be glad if I knew you'd think about it for a moment... how sick your country appears from the outside when one reads about so many medicines and so many disorders and about medicine for .... anything slightly uncomfortable. And how all these trendy things migrate to other countries, where people don't even know that their moods, sadnesses, uncomfortable moments, their life in a word, is a disorder.

Here's my answer:

The short answer to your question is: yes, there are many such patients here in the U.S. However, most of these "patients" do not need these medications, most do not need psychiatry at all. Of course many do, they are truly sick and but for psychaitry their lives would be chaos. But the majority do not.

But they come to psychiatry because they are told, almost constantly, that there is something wrong with them. That the fatigue they feel, the emptiness, the lack of interest or sexual appetite or sadness or irritability-- all of these things could be helped by medications.

It happens that these "symptoms" occur in the absence of a clear cause, and medicines do help. But the majority of the time these are symptoms only because they are compared to someone else. Testosterone patches are the new big thing in psychiatry. No, I'm not kidding.

I'm not sure what a lack of sexual interest in a 40 year old is-- but certainly in comparison to any TV show, it's going to seem low. That preys on people-- a man worries that his wife is judging him, even as she is worried he is judging her; so both are worried, essentially, that the other person has agreed to accept TV as normal and feels consequently inadequate. Etc. If you doubt this, watch two married people try to sit through a sex scene in an episode of Sex In The City, or Mad Men, etc, together. They're both going silently insane.

They are handed images of life-- TV, etc-- and they think that they are supposed to be that.

The complicated answer to your question is that American society isn't really capitalist, it's mercantilist. Americans don't want riches, they want what they are told to want. They don't want a nice car: they want a Lexus. They don't want a nice house; they want a Viking refrigerator, granite counters. They don't want nice things: they want things that represent nice things. Americans want brands. While everyone was orgasming over The Tipping Point, they should have been reading this.

As such, psychiatry isn't a field serving a need; it is a product creating a market. They didn't need treatment; they were told they needed treatment. Just like you don't need Nike shoes, you're told you do. Granted, having Nike shoes or psychiatric treatment can still be helpful, but most can certainly get along without it and, dare I say it, neither is worth the price.

And when someone says, "I didn't really want Nike shoes, I just got them because they were on sale," they have inadvertently proven my point. You bought them and you didn't even want them, they were the default. "But I needed to buy some kind of shoe." Think it through...

Psychiatry-- medicine-- is too gigantic of an industry to bend to the whims of reality. It will create a market because too many people's economies depend on it. It's too big for Obama or anyone else to change it. Fox News and MSNBC can yell at each other all they want, it's already been decided: Wellpoint's stock has soared since Obama rolled in. The "public option" is now Aetna.

This is how it has always been throughout history. Did Europeans really blast cannons at each other in the 16th-17th centuries because people desperately needed more spices? Yes, they actually did. A third of the Triangular Trade was rum. People died over rum. Not depleted uranium or alien artifacts or the Spear of Longinus: rum.

You ask whether it is worrisome that the rest of the world might see American as a bunch of invalids. Well, that maybe true: but what do we care? We're the only people that matter, all other people are supporting cast.

Your final point is the most important: All of this is coming to a town near you. All of this nonsense talk about whether American is losing its global dominance is a ruse. As long as America remains the largest current market, it sets the standards. The Chinese are going to want to need Viking refrigerators.

True power rests in the hands of those who define our cultural models and decide what we want to need or who we want to pretend to be.

The history of the world is the history of mercantilism; the history of men bending government to fight to the death for things they don't really need and only barely want.

===== ====== ===== The Last Psychiatrist: Are Women Prone To Paranormal Beliefs?

you have a better explanation?

A reader sends me this email:

Subject: Guilty as charged.

https://thelastpsychiatrist.com/2010/06/are_certain_behaviors--_and_jo.html

http://www.bakadesuyo.com/is-belief-in-the-paranormal-a-feminine-trait

Does this mean I'm a bad person?

--
Eric Barker
Blog | http://bakadesuyo.com/

No, it doesn't make you a bad person, but the author of the study is suspect.

II.

The title of the article Barker had linked to contrast with mine is, Who wants to believe? Associations between digit ratio (2D:4D) and paranormal and superstitious beliefs.

Abstract: [...] This evidence may be informative for narrowing down possible developmental pathways of paranormal and superstitious beliefs. Propensities contributing to sex and individual differences in these beliefs probably arise in utero, may partly be due to prenatal testosterone and other prenatal programming effects, but less likely due to pubertal-adolescent androgen action or developmental instability.

Who wants to guess which way the association goes? Of course it does.

III.

These articles rely on the fact that you're not going to read them. Only the titles. Since they are done by academics, they are appeals to authority. A leading title, a leading abstract-- let the public extrapolate from there.

And who can sit through these articles? They are intermittently seductive and impenetrable. Open with the sexual differences in schizophrenia, then the similarities between it and paranormal beliefs, and close: "All of this points to a possible role of sex hormones for a suite of related or overlapping traits that include paranormal beliefs, schizotypy, and psychosis-proneness." Game on.

And if you do venture further into the paper, it's protected by landmines like this one:

Directional asymmetry in digit ratios was calculated as DR−L = R2D:4D-L2D:4D. Composite standardised fluctuating asymmetry (Møller & Swaddle, 1997) of 2D and 4D was calculated as FA = {Σd |Rd-Ld|/[(Rd + Ld)/2]}/2, whereby d = 2D and 4D, and expressed as a percentage of trait size (i.e., multiplied by 100).

That means there's science being done in there, got it? By experts, who can tell a nuclear reactor from an UPS truck. Stay the hell out, just read what you're told to read, i.e.:

In sum, the current data suggest biologically based, prenatally programmed influences on paranormal and superstitious beliefs. Or, paraphrasing the probably best known slogan from the defining X-Files television series: it may well be that some of the truth is in the womb rather than out there.

("Wait a second-- wasn't the X-Files audience mostly men?" I said shut your hole.)

The article expects you do not bother to read this:

For women, corresponding relations were all not significant. Second, among women, finger length was significantly negatively associated with total and positive superstition scores (and marginally significantly associated with negative superstitions). And third, associations of paranormal or superstitious beliefs with DR−L or finger FA were directionally erratic and for both sexes throughout not significant.

Or this:

Corresponding associations among women were throughout not significant, and directional asymmetry in digit ratios (D_R−L) was neither associated with paranormal nor superstitious beliefs in men or in women.... Paranormal and superstitious beliefs are female-typed traits, so the current results are exactly the other way round. For now, it is difficult to put forward plausible explanations for this pattern.

Because those things say, "oops."

IIIb.

Where the study went wrong is that last sentence, "paranormal beliefs are female-typed traits." I'm not sure why that is stated as if it were obvious, but leave that aside: that was what they study set out to show, right? So you can't make that the basis for the interpretation of the results. "We wanted to determine whether this drug cures cancer. Since we already know that this drug cures cancer, the fact that it didn't cure cancer is difficult to explain using conventional paradigms. Further research is warranted."

IV.

The point of research isn't discovery, it's confirmation. And the purpose of research articles isn't to convey information, but plausible deniability, exactly like in the intelligence game.

Did the author lie? Nope. Is the article methodologically flawed? Nope. Everything in there is factually accurate. But.

The beauty of the paper is that at no point did he have to say, "chicks will believe anything." He got you to say it.

Did he say paranormal beliefs were feminine traits? "I didn't write that, you guys misinterpreted the study." But that was the purpose of writing it that way. If you didn't want it misunderstood you would have titled the paper, "My Baffling Discovery That Paranormal Beliefs Don't Follow The Sex- Specific Patterns I Wanted Them To, WTF, I'm Going On Break."

Nor do I suspect he's malicious. He truly believes they are feminine traits, and amazingly his own study is unlikely to have dissuaded him. He knows he's right. The science is just padding. Even if all the studies turn out to be negative, he just needs to point at the stack: "look at all the research that has been done on the question of paranormal behavior and sex differences!" You look at the stack, five meters high, and think, "guess it makes sense. Chicks will believe anything."

V.

Do you think I staged this? That it's a coincidence that bakadesuyo.com guy sent me this article, that happened to conform to what I'm saying? This is the norm, not the exception. There are no exceptions. All of this is about handing you all the tools you need to lie to yourself.

You make a false distinction between "politics" and "science," one based on argument and the other on "objectivity." They are of exactly the same form, conducted in exactly the same way, by exactly the same people.

Both are done by humans, humans who want. Whatever truth is out there is barely detectable through the mist of envy and need and hope. They will make their words and their numbers say anything they need them to.

You want something uplifting, well, here you go: we have enough excellent raw data that we could make huge leaps in science without performing one further experiment. We could take all the, say, antidepressant data, and run it through the Machines to determine that it cures the flu in whites born in Virgo but only left handed ones who eat lots of broccoli-- and we have no idea why-- as long as we were willing to put aside our attachments to words like "antidepressant" and "Virgo" and "flu."

But that would require us to ignore all the previous interpretations of these studies which form the basis for our current postulates. Can you unlearn what you think you know "feminine" means? Not without a biological EMP.

I'm not making some philosophical/positivist case for the limits of human knowledge, I'm simply observing that when they want that brown square in the sat photo to be a nuclear reactor, then you'll want it to be a nuclear reactor, no matter how fast it's going.

----

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Are You Good At Reading Faces?

Do I look like I'm bluffing, bee-atch?

Can you correctly identify emotions if they only briefly flicker across the face? How good do you think you are?

Try the test.

Was a certain emotion harder or easier for you? Did it seem like some of the faces flickered faster than others? It may not have anything to do with the emotion. It might be the test.

Did you notice how some emotions flicker across the screen faster than others? (They don't, really.) This might lead you to conclude that you are not as good at perceiving certain emotions. But that might not be the case.

The problem with the test is that certain expressions in this test lateralize to one side of the face-- the expression is mostly visible on one side. (See contempt 4 and 8.) Depending on which emotion is displayed, and which side of the brain is dominant in you, reading one side of the face may be easier or harder for you.

For example, contempt goes to the boy's (4) left face, but girl's (8) right. It might have been easier (or harder) for you to perceive if it went to a given side.

To show this, get a mirror, place it perpendicularly on the screen on the z-axis (out), facing the side of the expression. Then, look into the mirror (not the screen) and see if the expression is easier or harder. If it is, the problem for you is lateralization, not expression reading.

As a rule of thumb, anger and contempt are naturally (i.e spontaneously) expressed on the left face of right handed people.

As an aside, I wonder if people who are "face blind" (can't read faces) aren't a) majority left handed; b) have the most difficulty reading right handed people's expressions, especially anger. Can they tell when a dog is happy or sad? (Considerably more symmetric in facial expression, don't ask me why.)

As an interesting experiment, photograph yourself making the various emotions. Then, video yourself (and I don't know how you'd do this) spontaneously making the expressions, for real (have a friend bring you a naked chick, a bag of maggots, your rival, Sandra Oh, etc) and compare. How does your fake differ from your natural? Look carefully. What part of your face did you "forget" to fake?

Liars are easy to spot, because they are faking their expressions. Pathological liars, however, are much more difficult, because they aren't really faking.

===== ====== ===== The Last Psychiatrist: Are You Mom Enough? The Question Is For What

at what age does it become incest?

"Has Time Gone To Far?" "Time Cover Causes Controversy." I heard people are actually offended by this cover. Which is worse, seeing this or a picture of two gays kissing? No, two gay women, of course, come on, don't be stupid. Alright, fine, but what if one's named Loshanda and the other one may as well be? Yeah, graphic design is hard.

I'll leave the discussion of the merits of attachment parenting to people who actually have parents and attachments, but it's kind of a moot point, I've seen more Taliban snipers than I've seen boob sucking kindergarteners.

So forget what Time is showing you, ask instead: what does the magazine want to be true?

Postulate: Time doesn't like breast feeding. If you disagree at least grant me that no one at Time thinks four years of it is admirable. Right? So you are supposed to hate her. Ok, how?

"Umm, 'how?' Well... there's a kid sucking on a boob..." Come on, man, that's weird but it's not hatable, hating her doesn't somehow reinforce who you are-- unless you're a woman who didn't breast feed. What if you're a guy? "Well, she's hot..." Right. The secret fear of marriage is that the kid wins the Oedipal drama.

At some point someone needs to notice that the intensity of the emotions about this issue are way out of proportion to the... prevalence of the issue. I'm pretty confident breast feeding on the way home from Webelos is a terrible idea but is it worse on your kid than getting divorced? Or staying together, depending? Extra year of boob or lifetime without a father. Hmm. Is this open book?

Other than the volume of your voice, do you have any reason to be sure of what you think?

So since Time has created a controversy out of thin air, we should consider that the controversy is a proxy for something else.

She's a billion, so either Time was writing a story on Attachment Parenting and found the hottest subject they could find to make it be ok, or they chose the hottest subject they could find to make it NOT be okay. So hot= shallow egomaniac using her boobs and then her kid to get noticed.

That's what Time wants you to think, anyway. But there are things you don't see that I can't unsee, which is why I've been at the bottle stashed behind the big rock at the creek's bend since I was a pre-teen. She's 26 and the kid is 3, subtraction= 23, so you have a super hot well manicured blonde having kids way the hell too early for a super hot well manicured blonde.................... and there are only two reasons why such a person would be pictured in American media: she's from Utah or Jesus is her co-pilot. Amen. The fastest way to get Time's Hatable Person Of The Week cover is to a) work for Goldman Sachs or b) praise the Lord. I guess it's possible she works on a trading desk but my money says this is a story about why religious people are insane.

So while the rest of you bah bah black sheep are led to complain that she's hatable because she breast feeds, when the Time comes-- and praise be to Jesus, it is coming-- for you to learn she's nipples deep in the Lord Is My Shepherd maybe you'll then remember which candidate you're supposed to hate.

There's hate in them there pictures, the worst kind of hate, the kind that makes you hate without knowing why, without knowing that you hate. The kind of hate that ends up defining you as a person in opposition to something else. And then you disappear.

Once you've made this prediction everything else is downhill. She'll homeschool the kid, which is hatable. She'll be wealthy for no identifiable reason: hatable. She'll be carrying around that kid 24/7 with no nanny yet still weirdly find time for mani/pedis and barre class. So hatable. And co-sleeping doesn't mess up her sex life or her sex interest because her husband plows her on the deck, in the car, in the pool, in elevators. Sigh hatable. You can't make a right on red but this woman is forcing the world to accommodate her, bend to her way, her life, and she appears to be succeeding and happy. Bitch.

Look at the comments as people struggle to explain why breast feeding a 3 year old is bad: they sense it's bad, but can't come up with a concrete reason to explain it. Well, Time is the magazine for you. They offer you a blonde cypher trusting that you'll solve it: she co-sleeps because she's a religious nut. Phew.

"When you think of breast-feeding, you think of mothers holding their children, which was impossible with some of these older kids," Schoeller says. "I liked the idea of having the kids standing up to underline the point that this was an uncommon situation."

That's Time's photographer explaining that simply having her breast feed wasn't good enough to make his point, he needed to stage the scene to "underline the point." This is why the sentence before that one is this:

Using religious images of the Madonna and Child as reference, Schoeller captured each mother breast-feeding her child or children.

If you have the urge to email me complaining that I'm defending religion or attachment parenting, please don't, your brain is broken. The point is to show you how the media e.g. Time manipulates you to hate some things by linking them to other things: it polarizes you, which means it makes you irrelevant. E.g. when an election "is determined by" one particular group of "swing" voters-- whom you deride for being too stupid to have made up their minds yet-- it doesn't mean your vote has been factored in but that you are so predictable that you don't count. Power never thinks of you as an individual. Power never thinks of you at all.

Maybe attachment parenting is good? Bad? Time doesn't care to find out. It could easily have PubMeded the story and found a hundred scientific articles to discuss. Nope. It needed space to tell me that Dr. Bill Sears was a Catholic, converted to evangelicalism, and back to Catholicism, and his wife goes to Mass every day. Oh, I get it, they're crazy people. This is a typical media trick, rather than exploring an issue it explores a person, describes him, his background and his faults, this is the kind of person who believes this, this complicated issue that is too difficult to understand on its merits. You're free to choose.

Do you think Time cares about breast feeding? Do you think Time cares about you? Time hates you. It hates everyone, especially its readers, it thinks of them as credit card numbers, as registered voters, as organ donors. It wants what it wants and if we have to throw a kid under a boob, so be it. Like Marshall McLuhan once yelled, there's a war going on out there, and it isn't between liberals and conservatives or atheists and believers or attachment parents and detachment parents, it's between us and them, where them is defined as everyone who is not us and us is defined as me. You lose.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: A Solution To The Pharma Problem

The problem so far is all arguments against Pharma (prices too high; no interest in making meds people need; no interest in cures, only maintenance treatments, etc, etc) fail because they are ethical arguments.

The problem and solution require our reluctant acceptance that the problem is an economic one, and only economics will solve it.

(If you haven't, read Part 1 here.)

Though I divide the solution into a "Doctor Side" and "Pharma Side," it is imperative that both solutions be executed simultaneously. Doing only one will absolutely fail.

Doctor side:

Pharma does not make meds for patients, it makes them for doctors-- they represent the demand. Read that again, that's Axiom #1.

Doctors have no current incentive or pressure to consider the cost (effectiveness) of the meds.
But without the pressure, there is no incentive from Pharma to create products that are cost-worthy. If doctors don't have to consider cost, then Pharma can effectively get doctors to add on, say Nexium. It works, so why not? If doctors must explicitly consider cost, then not only can't Pharma successfully market Nexium, it will not even bother to create it. Pharma will work on something that's really worth the money.

Consider also that unlike other consumer products, price has no relationship to relative value. Nexium and Lipitor are the same price, but (arguably) Lipitor is more important.

So doctors need to consider cost, which in turn will force Pharma to consider cost. So doctors-- not patients, President Bush-- must be given a healthcare budget, specifically a pharmacy budget. $20 per patient per day. Go.

That changes the market. If you do that, prices come down, especailly for "luxury goods" (e.g. Nexium.) And Pharma will create wonderful things (not that they haven't already.)

Pharma Side

Axiom #1 is: Pharma makes meds for doctors, not patients.

Corollary: They don't need to make a drug that is useful, or is awesome; only a drug that doctors will prescribe. Sometimes the two are the same, but that isn't by design.

Pharma gets no points, no credit, for creating drugs that work, only drugs that sell. No one I know has hugged a Lilly rep, thanking them for having a drug that works, even if imperfectly. Their only thanks is the money.

The single problem from the Pharma side is the blockbuster drug model.

The common criticism against the blockbuster model is that it entices other Pharma companies to invent "me too" drugs-- another SSRI, another statin, another Nexium.

But there is a much greater, critical, consequence of the blockbuster model: it makes doctors think that the mechanism of action of the blockbuster is the only, or most, important one-- it creates a paradigm that is hard to think outside of. In other words, the blockbuster model confuses science. It may be that lowering cholesterol is itself a red herring, and that the actual benefit is something else-- consider Vytorin lowered cholesterol more than simvastatin alone, yet was not better at preventing intima thickening. But because cholesterol drugs-- nay, HMG co-A reductase inhibitors specifically-- are the big drugs, that's all doctors think about.

From 1980-1998, SSRI were all psychiatrists thought about. So obsessed were they with SSRIs that they tried to explain nearly all psychic phenomena by serotonin. Depakote was such a blockbuster that people couldn't even comprehend a "mood stabilizer" that wasn't an antiepileptic.

You can't get a novel mechanism passed an NIH grant reviewer; Pharma isn't interested either. How is it that 6 atypical drugs all have prominent serotonergic activity, but no one investigated glutamate? You have a working paradigm, you have stuff that is well established, it's hard to abandon it and try something new. Not when you operate on the blockbuster model.

And meanwhile, Pharma loses out on new opportunities. Pharma may have already invented a novel mechanism drug that reduces heart attack risk-- but not only does it have to bring it to market, it has to retrain doctors that they trained to be statin obsessed-- that cholesterol, after all, isn't everything. Strattera and Cymbalta-- both invented at the same time as Prozac-- languished in Lilly's basement because the world (of doctors) was not ready to hear about drugs that weren't "selective" or serotonergic.

But as long as doctors don't have to consider cost, blockbusters are the best way to make money. You want to make a drug that doctors will simply add on to everything-- and they will, if they're not paying.

The Incentive Model:

Broadly, there are three categories of people working from different incentives.

For Pharma researchers, the incentive is to get FDA approval for an indication.
For reps, it is to get market share. Many reps compete against other reps in their own company. (e.g. if they come up with a great sales pitch, or have an awesome speaker, etc, they don't want to share them with other territories.)
For managers, it is indirectly market share, more directly certain rep based metrics (reps made growth targets, reps conducted the right number of programs, all expense reports were done on time, etc.)
For the company itself, the current incentive is to create what doctors will prescribe.

It's obvious that the incentives are different, and none are actually in alignment with the company's goal of increased revenue.

1. Bringing a drug to market should not be incentivized, even from the basic profit perspective. Just because it gets an indication, doesn't mean it will generate any money. But since researchers are incentivized precisely on that, you see a lot of obvious "me-too" drugs and indications. The fix here is to incentivize researchers based on the future success of the drug, not the indication. Coupled with a pharmacy budget for doctors, the incentive will be to invent a drug of value-- whether in a disease that has few treatments; or a significantly better/safer alternative. While more difficult, it will be more profitable to the researcher than another SSRI (which doctors won't want to spend their budget on.)

2. Market share is also a bad metric, yet it's the one everyone uses. It does not matter at all that Seroquel has more market share than Zyprexa because they may not be used for the same things. It's not Coke vs. Pepsi. As an example, for Lilly, Zyprexa competes against Geodon, but not against Depakote-- because it doesn't share the same FDA indication-- even though in the treatment of bipolar, Depakote is a much bigger competitor than any antipsychotic. If Zyprexa wins all of Geodon's market share, it gains very little in real dollars. But convert all the Depakote to Zyprexa, and Lilly wins.

3. Managers. I am not really sure if there is any value to managers. I am not being glib or insulting, and I'm open to information. But my read is that Pharma could easily cut the number of managers in half, reducing expenses but also freeing reps to focus on selling. Or, it could use a mentor model where good or senior reps are paid extra to mentor newer reps.

4. Next, you have to incentivize Pharma to make valuable drugs; at least don't de-incentivize. There is a gigantic likelihood that any really useful drug will be commandeered by the NEJM's Marcia Angell and her band of merry socialists. Why would any company would want to spend any money on a cure for HIV, when there is a real chance it will be stolen by the UN even before it gets approve?. And we're supposed to accept that, because society "needs" it. "Sanction of the victim" is what Ayn Rand called it (and I'm confident I just lost readers by invoking her name. Bite me.) So instead, you know what Glaxo's next big drug is? Treximet: Imitrex + naprosyn. Commandeer that, Dr. Angell.

The Research Model:

The current model is completely broken. Allowing "thought leaders" to peer review grant proposals is as good an idea as allowing senior Senators to choose your next President. Letting Pharma do it is like letting Coca-Cola decide your breakfast cereal.

I recognize that it can't be fixed all at once, so I propose an incremental solution.

Pharma puts money into a pot to fund independent research, no strings attached.

They can still fund their own stuff, of course, but we need a pool of non-taxpayer capital that private research can use. I recognize this is an expense for Pharma-- but not huge, NIMH budget is $1.5B-- but it earns considerable respect, and will likely lead to new ideas and directions-- and someone at Pharma will ultimately benefit.

The problem is who will manage this pot: putting it in the hands of "thought leaders" and academics is stupefyingly obviously a bad idea. You may as well let the Politburo decide. (Yeah, I said it.) Want to know what that would look like? The NIH.

The solution is a "Digg" style voting of research projects. Any doctor-- not just psychiatrist, because you need people with different mindsets to make good evaluations-- can vote up or down a research idea/protocol. If you want to get fancy, they can also vote up the amount the study gets (as opposed to simply approving an amount.) It's possible that allowing other scientists to also vote could be of benefit, but there are some problems with it that I haven't worked out.

Again, Pharma and the NIH can continue the same biased, barely readable quasi-research they have always done, this is just another funding source.

===== ====== ===== The Last Psychiatrist: As The Population Ages, Will Suicides Increase?

Don't bet your life on it.

An editorial in AJP opens,

In most countries of the world, older adults kill themselvesat higher rates than any other age group. Given that the leadingedge of the large post-World War II "baby boom" cohort willreach the age of 65 in 2011, demographers predict a rapid risein the number of seniors taking their own lives in subsequentdecades. The need for effective approaches to late-life suicideprevention is pressing.

No.

First, I'd like to debunk the prevailing belief that almost all suicides are due to a psychiatric illness, a belief he supports using an article he himself wrote that references studies that don't actually show this.

Construction Of Pathology

Simply assuming anyone who commits suicide is therefore "somehow not normal"; or "only someone mentally ill would kill himself" is wrong.

If a serial killer says, "kill yourself or I kill your kids" and you kill yourself, are you mentally ill? Was Ajax mentally ill?

Consequently, the fact that you committed suicide is not proof of illness, in the exact same way that death cannot be proof of pancreatic cancer.

Attributing causality to a complex behavior is masturbation with words. How is killing yourself from MDD different than killing yourself because of terminal pancreatic cancer? Note that the syntactic construction forces me to say "from MDD" but "because of pancreatic cancer." But is that a real, existent distinction?

Is it the same biological mechanism? Different? Note: "He was depressed, he killed himself, for no reason, his life was great." The presence of pathology is assumed because of the absence of causes; psychiatry abhors a vacuum.

While it is clear that suicide is a risk in depression, the issue here is whether one can assume depression if they committed suicide?

Three Problems Of "Psychological Autopsy"

Hearsay:

The evidentiary support for the presence of mental illness in those who commits suicide is mostly determined not by a past history of diagnosed psychopathology, but by a post-mortem psychological evaluation ("tell me what he was like?") in which the deceased has drastically biased everyone around him by killing himself.

A psychological evaluation is basically interviewing "informants" (e.g. family), over three hours, asking psychiatric screening questions to determine diagnoses. Think about this, seriously think about this. The guy is dead, and you're asking the family if this guy ever exhibited signs of mental illness.

The closest analogy is doing a post-mortem of a marriage by only asking the ex-wife. "The evidence strongly suggests 75% of divorced men are manipulative jerks." Oh.

Validity of Symptoms Descriptions:

Example, from one of the sources of the above article:

Where subjects suffered both physical illness and depressive symptoms before death it was often difficult to judge whether a depressive episode was present. To ensure a consistent approach to diagnosis, we took possible depressive symptoms at face value; thus, if a subject was reported to suffer tiredness, this was included as a depressive symptom regardless as to whether it may have been due to physical illness.

Go figure: 77% of these people "had" a psychiatric diagnosis.

Generalizability:

So it's legitimate to ask, what percent of suicides have ever been diagnosed before they died? What percent have been to a psychiatrist or primary care doc for psychopathology? The answer varies from 30-60%, which is another way of saying 40-70% have never been. A full 75% had never attempted suicide in their lives-- this was their first and last attempt. It's important to keep this in mind because the point of the editorial is to offer the elderly "access through a care manager to algorithm-driven treatment"-- yes, that's what he wrote-- then you're going to help a maximum of 45% (the so far best response rate in psychiatry) of the 50% you actually ever meet.

Part 2 here.

===== ====== ===== The Last Psychiatrist: A Study Finds Antidepressants Don't Work, And Suddenly It's October 25

ABC News, and others, report that the NEJM study found that antidepressants "may be duds."

Climb on the bandwagon, my bolsheviks, no brakes, no driver, let us see where it takes us.

Amidst the nearly unanimous "I told you so! Pharma has been lying to us!" the most important question of all goes unasked: why was this article written? Did no one think about the consequences?

An article like this has consequences, widespread social consequences. They are massive, you just don't see it.

Let's say antidepressants really don't work, and this could/should have been known. Have the last 10 years of psychiatry been a lie? It was all a shell game? If so, is anyone going to step up and apologize, take responsibility? "We were wrong, we've been pushing sham treatments-- sorry?" I don't want to hear, "we suspected this..." I want someone to stand up and announce, "you know, I've been prescribing these for years, and I now realize I was duped."

If it's true, then what were we doing to all those patients all those years?

These guys write this as if to say, "I told you so." It's all so clear to them. And to read the interviews, you'd think they were sipping on a Diet Coke-- poured into a glass, with a lime-- smugly announcing what they've known all along.

These guys are hailed as some sort of heroes, exposing the lies of Big Pharma. But they aren't, they are the worst possible self-promoters; they should be ashamed, they should be ashamed to show their faces in public, let alone practice medicine. They are worse than hypocrites, they are unconscious hypocrites.

Before you email me saying, "what-- you didn't want this published?   You want them to simply pretend everything is ok, that the data for the meds really isn't weak? That data isn't really being suppressed?" let me state my point as clearly as possible:

THE PROBLEM ISN'T THE STUDY WAS PUBLISHED, THE PROBLEM IS IT SHOULD HAVE BEEN PUBLISHED 10 YEARS AGO.

It's the exact same data they had 10 years ago, the exact same data. This isn't a discovery, this isn't Woodward and Bernstein, this is a bunch of academics who are no longer on Pharma payrolls who have now decided that they have nothing further to gain from pushing antidepressants.

Now they can pretend to be on the side of science.   We reviewed the data, and found some of it was not published.

You knew that already. You were the ones who didn't publish it-- it's your journal. Turner worked for 3 years as an NIH reviewer. He just notices this now?

Is no one wondering how it is that this study comes out now, when all antidepressants but two are generic?

As suspicious of Pharma as everyone is, no one seems to see that they are no longer getting Pharma money, they are now getting government money-- NIH-- so they're going to push the government line. No one finds it at all suspicious that the two biggest NIH studies in the past two years both found the generic to be the best?

You think that in 2000 those studies would have been published? But now-- 2007, 2008, if they'd found Cymbalta to be the best on the NIH's dime, you think that they'd get re-funded? What's the difference? Same authors, same studies, same data. All that's changed is the climate.

People want a direct financial link to show bias, not realizing that bias is much more prevalent and more powerful elsewhere.

And oh boy, there is going to be hell to pay.

This study isn't just about antidepressants, it is a call to arms-- and I'm sure these guys had no idea they were playing with revolution-- it's the rally cry of the disenfranchised, the powerless, who will say, "look, see! Big Business! Everyone leeching off the poor public!"   Do you think ABC News picks this story up because they care about antidepressants?

Again, I'm not saying hide the study-- but publishing this 10 years ago, with the same fanfare and media attention, would have prevented the coming storm, the storm caused by them-- and others-- and others-- the building anger and resentment-- not to mention maybe altered psychiatric practice in the first place. All of this could have been prevented. IT'S THE SAME DATA. But no one cared then. Times are different, I guess-- because the people are not.

Huckabee wins Iowa; recession looms under the direction of an insecure but resentful, spiteful, Fed Chairman-- even as oil goes to $100 and no one cares; China rises, Pakistan falls, and Russia is a viable solar energy plan away from collapse; pointless obsession about NSA eavesdropping, while Google and others shuffle along archiving your DNA, voice, and existence, all for future governments to decide what to do with; a public anger and distrust of the "system" that rivals the 60s coupled with an apathy and narcissism that rivals, well, any time, ever.

We are doomed. Look on my works, ye mighty, and despair. Nothing besides remains.

The Cold War ending had the reverse effect of making socialism ok to consider. And socialism combined with public apathy and near total control over the existence of information is...

You want to salvage your kids futures? Forget about bonds, forget about gold. Buy Google.   You'll get your chance tomorrow, when we collapse.

===== ====== ===== The Last Psychiatrist: A Surprising Number Of Teens Think They'll Die Young, Or Live Forever, Whichever Comes First

An unsurprising number of adults don't care either way.

CHICAGO - A surprising number of teenagers -- nearly 15 percent -- think they're going to die young, leading many to drug use, suicide attempts and other unsafe behavior, new research suggests.

The study, based on a survey of more than 20,000 kids, challenges conventional wisdom that says teens engage in risky behavior because they think they're invulnerable to harm. Instead, a sizable number of teens may take chances "because they feel hopeless and figure that not much is at stake," said study author Dr. Iris Borowsky

15% is surprising-- because it's smaller than I would have guessed, no? How many teens did you know in high school who thought they'd die by 30 (their parents' age when they were 4...?) or 33 (Jesus?)?

The really surprising thing is the logic: how do they make the jump from thinking you'll die young, to using drugs? Is it only those 15% who use drugs? Do the majority of those 15% go on to use drugs? etc.

How many teens think they will live forever? Not like vampires, but how many can't imagine their lives three years into the future, let alone 30, and this finds expression in the sentence "I'm never going to make it to 35"? It would be equally (in)valid to conclude, "teens belief that they will live forever leads to risky behaviors."

II.

Borowsky said the magnitude of kids with a negative outlook was eye-opening. Adolescence is "a time of great opportunity and for such a large minority of youth to feel like they don't have a long life ahead of them was surprising," she said.

Yes, I'd expect someone of my generation to say something that obtuse.

III.

Adolescence is supposed to be an identity Schrodinger's Cat: multiple simultaneous states which eventually collapse into only one. The goal of adulthood is to let go of the other possible existences and to make the best of the one. A successful adult is one who understands that it doesn't matter which life you ultimately pick, only that you live it well. The same potential for, say, happiness exists whether you are a construction worker, porn actor, or wealthy industrialist.

Meanwhile, it is in no way contradictory for a teen to think he'll die young AND live forever; or that he'll become a chef AND be an infantry colonel; that he'll raise his kids on a farm AND roam the earth celibate like Kung Fu.

But the idea that kids are having multiple potential lives, simultaneously, doesn't sit well with adults, especially when the adult is more concerned with how the kid impacts their life, not the other way around.

IV.

As an aside:

The study suggests a new way doctors could detect kids likely to engage in unsafe behavior and potentially help prevent it, said Dr. Jonathan Klein, a University of Rochester adolescent health expert who was not involved in the research.

Of course it does. Because in the new era of healthcare, there's no money in the treatment, only in the detection. Question: once detected, what do you propose we do about it? It's a deadly serious question, I want a serious answer. You can't give them Zoloft, they're not yet "sick." Will you put them into therapy against their will? Monitor them? Social services? Outsourcing the parent? It takes a village, etc?

You are witnessing the nationalization of parenting.

Question: why would a parent want their parenting outsourced? Oh, yeah.

VII.

Does the study really show that kids who think they're going to die young engage in riskier behaviors? No. Not even close.

First, the trick of the study-- and it is most certainly a trick-- is to present the strongest data first, but report the weakest data in the press, and conflate the two.

Here's the strongest data in the study-- not found in the press story:

In adjusted models, illicit drug use, suicide attempt, fight-relatedinjury, police arrest, unsafe sexual activity, and a diagnosisof HIV/AIDS predicted early death perception at time 2 (1 year), time3 (7 years), or both (adjusted odds ratios: 1.26-5.12)... Adolescent involvement in risk behaviors predicteda belief in premature mortality 1 and 7 years later.

See it? I'd call this "Bait And Switch," but I already used that for another post title. Here, the data shows that kids that are already being risky will later on in life believe they are going to die young. But the press reports it the other way.

Look at the study more closely, or once anyway, and you'll observe that

1. although 15% of kids said they probably wouldn't make it to 35, only 3% actually voted as having "no chance" or "probably would be dead."

2. Six years later-- when they're no longer adolescents-- only 17% of the 15% still thought they'd be dead at 35.

3. There was no difference in actual death rates.

In other words, very few kids actually believed they'd be dead, most kids grow up eventually, and it doesn't matter what they think.

VIIb.

Hard data for early pessimism predicting individual risky behaviors:

death prediction.JPG

I'll grant you that predicting a suicide attempt makes sense; and I'll grant you that the relationship to HIV seems strong with no clear explanation. But beyond that, there is very little you can predict from early pessimism; and certainly nothing that justifies the article quote at the top.

"Oh, the press misunderstood our study..." Sure they did.

The best way to create a public health problem you can bill for is to allow a journalist to report your findings.

VIII.

"But even if the reporting isn't accurate, surely the data themselves are valid? Numbers are numbers, right?"

They used to be.

Here's an example: in the study, they make a big deal about separating out the races of the kids, because of course different races can have different perceptions about their futures. Fine. Meanwhile-- think about this-- they question as "adolescents" all kids grades 7 to 11. Do you remember the gigantic difference between 8th grade and 10th grade, let alone 7 to 11? Well, they can't. To them, it's all just "adolescence."

One of you is right now thinking, "well, how could this study have been done better?" You're asking that because you've been brainwashed: there was no need to do this study at all. This is not a question that needed to be answered. What if 100% thought they'd die by 35? Or 0%? Do any of these results tell you anything? This is another one of the quadrillion self-referential, running-in-place studies that constitute academic research. They tell us nothing about the world around us, they are solely masturbation.

FYI, someone funded this study, and it wasn't Pharma.

IX.

But even masturbation can be beneficial if it is done with a pure and selfless heart. So let's be fair: does this study and story contribute to the understanding and betterment of adolescents?

Turns out the answer is mocking laughter followed by scorn. The researchers, and the press, have no actual interest in helping adolescents or even understanding them. Their interests lie first in themselves, and the kids only in how they impact that interest. For example, based on her comment, what Borowsky finds interesting about her study isn't the ability to predict future risky behaviors, but that kids don't share her optimism. "Wow, would you look at that!" If all adolescents were optimistic about their future, she'd have thought that was completely normal.

Here's another example: the authors of the study cite references and make hypotheses about the causes or meaning of the kids' pessimism. This is strange, and by strange I mean it figures, because when they did this study they could simply have asked the kids themselves. It, apparently, never occurred to any of them. That's precisely the point.

You might say, "well, maybe the study was such that they couldn't get kids' feedback..." Then why do this study at all? The core question everyone would want answered you don't even ask!

To trade a generalization for a generalization: they, The Dumbest Generation Of Narcissists In The History Of The World, does not care about their youth. They care about them as a body, as a construct, but not as individuals, not as people with their own lives, hopes, wants, etc. That's definitional narcissism, in case you thought you were on TMZ.com.

Oh, they care about them in societal or general terms. "What should we do about these kids today?" the way someone might ask about penguin overpopulation or the quality of bottled water. It's too much hard work to look at each individual kid, in the context of their own environment and their own lives-- hard work previously undertaken by parents, but as I've said we're in a new era-- and then deciding if there's any pathology. It's much easier to use, as a shortcut, the extent to which a kid disrupts the life of the nearest adult.

Adults have virtually no interest in teens as human beings; they are voyeuristically consumed with knowing what they're up to, and love chatting about why they do things. To them, understanding is parenting. Let someone else do the actual work; they have a Time Magazine waiting.

X.

One last example. Teens like movies, they identify with characters, for better or worse sometimes those characters are the blueprints for their current or future identity. In other words, the characters matter.

When Time did a story on Borowsky's study, this is the movie they chose to depict this new generation of pessimistic nihilists:

If you want to show how completely oblivious you are to the perspective of today's teens, this is how you do it. Why not throw in Jethro Tull? They didn't even make an attempt at finding a current reference.

I'll say that last part again, because it's the key: they didn't even make an attempt, because it wasn't important to them or their readers.

-------------------

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Atkins v. Virgina and the Execution of the Mentally Retarded

Once again, I appear to be all alone.

...Because of their disabilities in areas of reasoning, judgment, and control of their impulses, however, [the mentally retarded] do not act with the level of moral culpability that characterizes the most serious adult criminal conduct... [over the past 13 years the] American public, legislators, scholars, and judges have deliberated over the question whether the death penalty should ever be imposed on a mentally retarded criminal. The consensus reflected in those deliberations informs our answer...

So opens Atkins v. Virginia, as opined by Justice Stevens.

It seems unassailable that the mentally retarded should not be executed. Justice Stevens spoke of a consensus; the APA's amicus brief to the Court stated:

(1) there is a clear and unmistakable national consensus against the imposition of the death penalty on persons with mental retardation, and (2) the American people oppose the execution of individuals with mental retardation because the practice offends our shared moral values. (emphasis mine.)

So once again I am the sole hold out to national consensus. Okay. If I am to grant that such a national consensus does exist-- which it most obviously does not-- it is not in small measure due to misunderstanding what mental retardation is: it isn't Down's syndrome. It isn't a guest spot on the Howard Stern Show, it isn't finger paints and a baseball cap at age 30 moaning, "I wanna eat tato chips!"

If it was this, I'd agree a consensus might even be close to unanimous. Ironically, such a consensus would be irrelevant as such individuals don't commit capital offenses.

But this is not what mentally retarded is. Atkins, the above defendant, was determined by the defense expert to be MR because of an IQ of 59. With this IQ, he was able to get drunk and smoke pot (which, FYI, does not diminish responsibility,) drive a car (which he was licensed to do), kidnap and drag his victim to an ATM to force him to withdraw $200, then drive him to an isolated spot and shoot him 8 times-- not to mention be competent to stand trial, cooperate in court and with his attorney, etc. He was also able to pull of 16 other felonies in his life. An IQ of 59 allows reading at a 6th grade level-- comic books are 4th grade and Time Magazine is 9th grade.

But that was Atkins. A diagnosis of MR is an IQ less than 70. Can someone with an IQ of 70 appreciate that shooting your kidnapping/robbery victim in the chest 8 times and dumping him in an isolated location is really, really, wrong? From 1976-2002, 44 people with "mental retardation" have been executed; all but 2 had IQs at least 58.

So a categorical exemption for the mentally retarded might be sensible if someone could tell me exactly what mentally retarded means. Because the psychiatric definition quite obviously covers individuals well within competency standards. And that's the point.

Here's an example: if the exemption was for "Down's Syndrome" then this would be plausible, because a) we can reasonably agree how Down's impacts the defendant; b) we can identify it. But "retardation" means-- what? Mentally ill, as an exemption, is worse-- does depression count? Only psychosis? Does the presence of only a hallucination count, or do you have to have a thought disorder? "Schizophrenia?" What's that? The John Nash type, or the homeless crackhead type? How about borderline? Narcissism? If you can't be sure of what constitutes "mentally ill", how can you make a blanket exemption for it?

We can take this debate up a level, and observe that with every other psychiatric disorder that impacts on legal matters, the question for psychiatrists is simply, "what's his disorder?" or "how does the disorder impact this case?"-- we have an advisory capacity, leaving the ultimate decision of culpability up to the courts. In this way, we put some distance from the outcome. That's what expert testimony is all about. Fair enough. But now, with MR, the diagnosis automatically gets you out of execution. As long as the IQ test comes back 59, the sentence changes. Mental retardation is binary, apparently, and if you are fortunate enough to have it, you live-- regardless of how well you understood the wrongness of your actions, or how egregious were the crimes.

Which is ridiculous. There are practically no valid measures for any psychiatric illnesses-- everything is up for debate and interpretation. MR especially is a continuum disorder. Factors as trivial as which IQ test is used, or when it is taken, can affect the diagnosis. One study finds a 6 point increase using older tests vs. the newer version of the same test.

"Our findings imply that some borderline death row inmates or capital murder defendants who were not classified as mentally retarded in childhood because they took an older version of an IQ test might have qualified as retarded if they had taken a more recent test," Ceci says. "That's the difference between being sentenced to life imprisonment versus lethal injection."

But now the law has set an arbitrary and empty, binary cut off for execution. Psychiatrists now actually choose the sentence. Not inform the sentence-- choose it.

I'm fairly certain the APA didn't think about this when it filed its amicus brief. They never think these things through, because they believe they are an instrument of social change. But, like forced medication to render competent to be executed, psychiatrists have now boxed themselves into a corner. It is now solely up to them-- and their "tests"-- to decide who gets executed.

Consider the ethical dilemma for a forensic psychiatrist asked to evaluate for MR: given that the defendant can fake MR; and given that finding the defendant does not "have" MR--or suspecting that he is faking MR-- is exactly equivalent to sentencing him to death, can there be any other medically ethical outcome than finding they are MR? Think well. In other words, an answer is forced, an answer is created, simply by asking the question. The situation here is identical to the judge leaning over and asking, "Do me a favor and decide for me. Should I hang him or put him in prison?" Um, well, gee, it's up to me? um, since you asked...

I know, doctors are going to inwardly smile, pat themselves on the back for their cleverness; after all, the goal is to abolish the death penalty for everyone, one group at a time. And I am sure there are organizations who will actively, openly, exploit this loophole.

Notwithstanding the laudability of this goal, this isn't about the death penalty, it's about who decides the death penalty.

Just remember, when society allows psychiatrists to decide who lives or dies, then psychiatrists will also decide who dies or lives. I want everyone on the planet to take a very deep breath, and think about this.

===== ====== ===== The Last Psychiatrist: A Trip You May Have Taken

He pulls over at the curb. All the shades are pulled down, the house looks dead. The house-- shack-- is on the beach.

He gets out of the car.

"Tracy," he calls out, expecting nothing.

He walks to the screen door. It's locked, but the inside door is wide open. He smells pot, and something that is not pot, and something that is feces. He has never seen this place, yet it is, somehow, exactly as he imagined it would be. It is also worse.

"Tracy!"

Tracy appears in the front yard, behind him. "What are you doing here?" she shrieks. "You weren't supposed to come until Thursday!" She looks like a crack addict.

She runs in the back door, cursing.

A man who looks like anyone from Cops except the cops comes and unlocks the screen. "You're Tom, right? My name's Sam. Pleased to meet you, I've heard a lot of great things about you that for all intensive purposes I feel like I knows you." There is no geographic reason he should speak with a drawl, but there it is. Obviously, he is not wearing a shirt.

"Where's Tracy?" He walks past Sam. The house is filthy. There is broken glass from what could have been a crack pipe pushed to the corner of the floor, and what still is a crack pipe is sitting hopefully on the TV, waiting for someone to hold it.

Tracy comes back. "You can't just come by whenever you want! You can't force me to do anything, I told you I wanted to do this but not yet! Fuck! My girlfriend's boyfriend just got locked up, and she needs me--" She yells more words at him.

"Get your stuff, we're going."

"Son of a bitch!" she screams, slaps a beer bottle off the counter and it smashes into the sink, more glass. She walks off, screaming something about a car and a guy from Arkansas. With her, it is always more and more words.

"Tracy, let's go! Now!"

Sam intervenes. "Don't worry about it man, I'll go talk to her. I'm really glad you came, she really needs help right now. Do you want a beer or something?" He has one ready, pops the tab and hands it to Tom, who takes it for no reason. Sam goes off to make things right, crunching some broken glass underneath his bare feet. His feet do not care enough to bleed.

There is more screaming.

A man knocks hard at the screen door; Tom instinctively locks it. The man looks like a ex-football player turned pro beer drinker. Big chest, bigger gut. No sleeves. He cups his hand over the screen to look in, then jumps back when he sees Tom standing there. "What's going on in there? Open this fucking door!"

Tom takes one step back, close to the kitchen cabinets.

"Who the fuck are you? Where's Tracy?!" He yanks at the screen door. "Open this goddamn fucking door or I'm going to fucking smash it--" and it bursts open.

Oh my God, Tom thinks. I'm going to have to kill this guy.

"Hold on, man," Tom says. "I'm her brother."

That was the only right answer. The sibling relationship is the only one respected in the streets. It's even, neutral. There's no assumption of ulterior motives. You're given credit for trying to do the right thing, and leeway because you're young enough to know the score.. If he was her father he'd be tossed. If he was her husband, he'd be dead.

"Oh, sorry man, that's cool. Things have been out of control here lately, people, crack, the cops, last week someone set fire to my--"

"I'm getting my sister out of here."

"Ok." He glares at Sam, who is peeking around a corner, and walks out. Tracy reappears. "Fucking--"

"Shut up. Get in the car."

Sam is overly helpful, he puts her bag in the car, goes inside, gets another bag and puts that in, too, then suddenly stops, reaches in, and grabs a bottle of pills. He looks back at Tom. "I don't know how you all are getting back home, but you know she's got an open warrant, right?"

"No, I didn't know that."

"It's not a warrant," she says, "the PO violated me because I had a hot urine, but she wasn't allowed to do that because I was already in treatment for it, so I spoke to her supervisor, a guy named Marins, or Marinis, Marins, something like that, I have his name inside with the other papers, and they told me that I had to get a doctor's note verifying that I am in treatment and that I am prescribed the Xanax for my anxiety, one four times a day. I never abuse my medications, I take it only as prescribed. My doctor knows that. That's why he trusts me with the Xanax. But I couldn't get to him because they don't allow walk ins, and the last prescription he wrote by mistake he wrote two times a day instead of four times a day, so the PO said that she had to technically violate me but since she knew that I was telling the truth about the Xanax I wouldn't be arrested. But then she got transferred, and she never changed the order--"

"Tracy," says Sam, "just get in the car. You're brother really cares about you, don't give him a hard time."

"Whatever."

Sam looks at him. "She really needs help. She's been diagnosed bipolar schizoaffective, she takes Seroquel but she's supposed to be on lots of other shit, but, you know, she doesn't take them. I always try to get her to take them, and I make sure she doesn't abuse them, and I makes sure she gets to her appointments. She's really lucky to have a brother like you, to come out and do this for her. " He pauses. "Do you want some beers? You know, for the road?"

"No, thanks." He shakes Sam's outstretched hand, but then Sam won't let go. "Look, could you do me a really big favor? It would really help me out a lot. I'm trying to get this apartment but the landlord needs me to verify that--"

Tom pulls his hand back. "Sorry, I can't help you."

"No, wait, hold up, it's really not a big deal, all I need is a letter--"

"Sorry."

Tom's face turns stern. "So that's it? After all the help I gave you here? I gave you my beer. I moved all this--"

"Dude, I'm not doing anything. I'm here to get my sister, and I'm leaving."

He takes both her bags out of the car and drops them in the yard. "Wait," she yells, "I need that bag, I have a pair of pants inside I have to return to--"

He gets in, starts the car. "Wait," she says, "I forgot my cigarettes-" He drives off.

Forty five minutes later, she says, "I need a beer. We need to stop somewhere."

Tom shakes his head in disbelief. "Yeah, sure."

"No, seriously, I'm going to have a seizure, I'm coming off it, I'm in withdrawal."

He looks for no reason, he wouldn't know what withdrawal looked like.

"Please, I'm not kidding here, I was taking like 12 Xanax a day, I'm going to have a fucking seizure--"

"Fine!" He pulls into a gas station, parks, takes the keys. "Stay right here. Do not get out of the car." He goes in, buys a six pack of beer. Walks out, throws three of them away. Gives her the other three.

He can actually see her get calmer with every approaching step. "I need to pee." Christ. He's with a three year old. She takes the beers, takes her bag-- which he snatches back out of her hand. She glares, goes off to the bathroom.

As he waits, he notices his sunglasses case is missing. Not the glasses, just the case. He opens her bag, it is pushed to the bottom. He opens the case. Inside is the tire gauge he didn't even know was in the car.

Then he sees her.

The beers are not in her hand. What is in her hand, balanced on her head, is a 3x4 ft picture, in a steel frame.

"Open the trunk," she says.

"What the hell is the matter with you? Did you just steal that from the bathroom?"

"It's all right, don't worry about it. No one will need it."

"What are you talking about?!"

"Come on, I really like it, this is my favorite photo in the whole world. I love Marilyn Monroe, she inspires me, she inspires me to get clean, this photo always reminds me of--"

"Give me that fucking picture," he snarls, rips it more aggressively than necessary from her hands, and walks back to the gas station.

"What the hell is wrong with you?" she yells after him. "It's just a fucking picture!"

He walks into the gas station. The attendant sees him, sees the picture, and does not want to understand. "I'm calling the police," he says.

"Look, this picture fell off the wall, so I'm returning it to you. Here it is."

"You fucking--"

"Here it is, I'm sorry, I'm leaving."

He comes back to the car, she is smoking a cigarette. Where did she get cigarettes? Where did she get a lighter? "What's your problem, man?" she says. "You're acting like I stole a guy."

"Get in the car. Just get in the car, and don't talk, don't talk to me, just don't fucking talk to me until you're sober." He is suprised he can't pull the steering wheel off.

They drive silently for about ten cigarettes.

"When I get out," she says, looking out past the highway into her dreams, "I'm going to move back to the beach, and I think I'm going to get a job working with vets from Iraq who have, like, PTSD, people who are self-medicating." He says nothing. She eventually looks over at him, honestly perplexed.

"You don't even fucking care about the vets, do you? You voted for Bush, but you don't even--"

"Shut up," he says, "all the time."

"You don't know what it's like for us."

He actually slows the car down. "Us vets? Are you a vet now?"

She rolls her eyes, you just don't fucking get it, takes a drag from the cigarette and blows it out the window. "You know what your problem is? You don't fucking care about anything, or anyone. That's your problem."

They keep driving.

I'd like to say there's an ending to this story, but unfortunately there isn't.

===== ====== ===== The Last Psychiatrist: Atypicals and Diabetes: Glucose Transport

Glucose is absorbed through the small intestine into the blood.

All glucose is taken into cells via hexose transporters: this is facilitated diffusion (no ATP). Facilitated diffusion is passive diffusion through a channel made by a transmembrane protein; the proteins are able to open and close this channel. There are many ways channels can be opened/closed: ligand gated (i.e. neurotransmitter receptors), voltage gated (neurons), or, in the case of hydrophilic molecules such as glucose, mechanically gated: the channel is shaped like a closed "V". Glucose goes to the bottom of the V, causes a conformational change and the "V" opens, but closes at the top (makes an upside down "V".) Glucose can pass, and the V recloses. All diffusion is down a concentration gradient.

The hexose transporters are called, randomly, "Glucose transporters 1-5" (GLUT1-5).

GLUT4 is the main transporter in muscle, fat, and the heart. GLUT4 is insulin-sensitive (though it can also be activated by muscle contraction-- go figure.) In the absence of insulin, GLUT4s are stored in cytomplasmic vesicles floating around in the cytosol. If insulin binds to the insulin receptor (an ATP dependent tyrosine kinase receptor-- NOT the GLUT4), a signal cascade is activated that causes the cytpolasmic vesicle to go to and bind to the plasma membrane and lodge the GLUT4 there. The GLUT4 then allows glucose to diffuse through. When insulin disappears, the insulin receptor reconforms, the signal cascade stops, and the GLUT4 pinches off (by clathrin and other contracting proteins in the cell membrane) into a vesicle again (pinocytosis).

Thus, if there is no insulin: even if there is much glucose, there is no signal for the vesicle to go to the plasma membrane and lodge the GLUT4, so there will be no transport of glucose into the cell; so glucose stays high in the blood. Thus we have Type 1 diabetes.

Insulin also stimulates the creation of glycogen in the liver and muscle. [Insulin activates hexokinase (1st enzyme in glycolysis) as well as phosphofructokinase and glycogen synthase) and inhibits glucose-6-phosphatase ((opposite direction of hexokinase, same reaction) gluconeogenesis).]

Insulin promotes fatty acid synthesis.
Once glycogen synthesis has maxed out (i.e. about 30g, about 20% of the carbohydrate part of a studied meal, max in 4-6hrs,) then fatty acid synthesis IN THE LIVER takes over. Glucose is converted to free fatty acids (FFAs) and dumped back into the blood as lipoproteins-- which are then broken up into FFAs.

FFAs go into the adipose cells of the body. Glucose also goes into adipose cells-- via GLUT-- and are converted into glycerols. Glycerol+FFAs= triglycerides.

Thus, insulin's role is to store fat and/or oxidize glucose. Too little insulin will also trigger protein catabolism.

GLUT1 and GLUT3 account for 95% of the glucose transport to the brain. GLUT1 is for the blood brain barrier (the tight junctuions of the BBB are what require these channels), and GLUT3 is in the neurons. (pic here) GLUT1 is also found in muscle.

These are not insulin dependent (like GLUT4 is) so the brain can continue to get its energy. Not only does the distribution of GLUT 1 and 3 mirror capillary density and areas of relative glucose utilization, the GLUT1/3 densities can change depending on chronically increased (or decreased) need for glucose. Interestingly, nicotine, which increases brain glucose utilization, increases GLUT1/3 but not capillary density.

GLUT2 and 7 are in the liver. GLUT2 can also carry D-fructose.

GLUT5 is in the intestine, and some glial cells of the brain.

Type II diabetes is insulin resistance, not lack of insulin. There is not, at least initially, a problem with the pancreas's secretion of insulin in response to high glucose. The problem is at the level of the insulin receptor and/or GLUT, which become insensitive to the effects of insulin-- because there has been so much of it for so long. (For more info, see: News Physiol Sci. 2001 Apr;16:71-6.

Next up: how do antipsychotics affect glucose/insulin/transporters?

(For a review: What We Know About Facilitative Glucose Transporters )

===== ====== ===== The Last Psychiatrist: Atypicals for Maintenance Bipolar

In my post on the NEJM article about antidepressants in bipolar depression, some people couldn't see how I made the leap to a political movement away from SSRIs and seizure drugs, and towards atypicals.

First, I'm not against atypicals. I have long advocated for fluctuating doses of antipsychotic instead of Depakote. I do think they can treat depressive states. I don't disagree with the study or the data.

What I find perplexing is the timing. I was trying to show how academic psychiatry has now decided to move towards atypicals. Why now?

Here's an example. Eduard Vieta just released his hit single, Current Approaches to the Treatment of Bipolar Disorder With Atypical Antipsychotics, in Primary Psychiatry. In it, there is only one short paragraph on Depakote, describing its one maintenance study, in which (it states correctly) Depakote didn't beat placebo. That's it. 81 words.

Find me one other article written before 2007 that is so curt and dismissive of Depakote.

It goes on to explore the data on atypicals-- and there's quite a bit. It rightfully concludes, "atypical antipsychotics have shown promising results in bipolar disorder maintenance therapy."

But here's the point: with two exceptions, all studies on atypicals referenced here came from 2004 and earlier. The two exceptions were from 2005.

So it's not new data, it's old data. Did they suddenly read the back issues? Holy crap, atypicals might work? That's why that NEJM piece is so important. It marks the point where academia has decided to embrace atypicals and move away from Depakote. If this move was really data driven, they would have done it in 2004. Hell, they would have done it in 2001 when the Depakote maintenance study didn't beat placebo.

There's no conspiracy here, there's no exploitation of the weak for personal profit. I'm not saying these are bad people, not at all. They are not conscious of it. That's what makes this politics, not science.

You have an academic career, you want to do clinical research, who's going to pay? NIH money is hard to get. So you turn to Pharma. You "get" to do a clinical trial of Depakote for the treatment of bipolar. When you're done, maybe they hire you to do another one.

You, personally, don't even get the money-- the department does, and they use it to pay your already set salary. But you get a career, an identity. But you start to believe the prejudices of your chosen stomping grounds, and ignore the shortcomings. You become a nationalist. You start to believe that Depakote is first line, despite data; or that all seizure drugs will work; or that this thing you called bipolar is actually what you're treating. That there are actually two poles.

Then the money dries up. But Abilify says, could you do a clinical trial of Abilify for bipolar? And you say, sure, why not? maybe Abilify could be an add-on? And then it's monotherapy. And then Seroquel funds a study.

The last part is when you don't simply move on from Depakote-- you distance yourself from it. "You know, its data was never that great, it was really just an antimanic, and anyway, it had horrible side effects." It's the next step of political hypocrisy: I was never really a citizen of that nation, I have really always been a citizen of the world.

===== ====== ===== The Last Psychiatrist: Autism and The MMR Vaccine

Just as I was writing about the consequences of ideological bias in autism research...

Mea culpa, I will admit that I never read the primary sources either. If I had, this blog would not exist, I would have quit psychiatry in 1998 and opened a bar called Cougars and made a fortune.

In case you do not have kids or ears, there's a controversy about whether the combination measles-mumps-rubella vaccine causes autism. The controversy arose from the observation that previously normal kids began to regress soon after receiving the vaccine.

If you had only a rudimentary understanding of the facts (e.g. most doctors, including me) and were trying to create an explanation, you would have intuited that it is either the virus in the vaccine, or perhaps you would have recalled the word "thimerosal," a mercury containing preservative in vaccines, which has also been linked to autism.

And you would have left it at that; on the one hand is the association, on the other hand is "the published literature" (or what you heard is the published literature) saying there is "no evidence of a causal link." (Well of course, they have to say that.)

And then approaches the peon with the autistic child, who, recognizing the limitations on medical science doesn't expect you to have a solution, but is hoping at least for a legitimate explanation. Your reply to this peon, who dares to ask a Medical Professional (expecting an insider's view of the data and an educated opinion, and not expecting you to simply make stuff up based on what you heard on CNN) is: "there've been some reports, but we simply don't know enough to blame the vaccine outright."

At this point, three things should have happened:

1. You should have wondered if "there've" is really a word, or if you just made it up. Maybe you just threw two words together that sounded like they fit? That's a metaphor for everything else you said.

2. You should have realized that you don't actually know if it is the MMR vaccine, or vaccines in general, that are the alleged cause of autism; and that you aren't even sure if there was/is any thimerosal in the MMR vaccine to begin with.

3. Your ignorance of contractions and medical information did not prevent you from spewing vague crap to your wide-eyed inquisitor; nor did it prevent them from believing you.

II.

It won't be giving anything away to tell you that the evidence for the link is absolutely laughable. But take a step back and look at the controversy itself. "Is it vaccines?" ---No, it isn't. ---Yes it is. ---No it isn't. The controversy is so powerful not because it's about vaccines, but because engaging in the controversy serves a more important function: the reinforcement of an ideological bias: "we don't have definitive evidence that the culprit is the MMR vaccine-- it looks like it is, but it may be something else. But definitely it is something that happens after birth."

III.

The controversy exploded with the publication of a single paper, Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. The title is not one that would be expected to herald a 10 year ideological war, but there you go.

First: the title of the paper that launched a million other papers, you'll observe, does not contain the following words: vaccine, thimerosal, MMR, combination. We'll get back to this.

The actual evidence is this case series of 12 kids who developed autistic features shortly after receiving the MMR vaccine. The entire basis for the link is this single sentence:

In eight children, the onset of behavioural problems had been linked, either by the parents or by the child's physician, with measles, mumps, and rubella vaccination.

That's it. If you're looking for something more solid than "parents or the child's physician" linking the two together, you're going to be disappointed.

You'd think that wouldn't be enough to merit a publication in Lancet, let alone a controversy. Let alone a substantial decrease in vaccination rates.

However, the focus on this extra, tertiary observation masked the real point of the paper, which was observing a relationship between-- read the title-- bowel inflammation and autism.

Get it?

No? Then it worked. You're not supposed to focus on it-- it's supposed to become unconscious.

Still confused?

Bowel inflammation is not natural; in other words,

Both the presence of intestinal inflammation and absence of detectable neurological abnormality in our children are consistent with an exogenous influence upon cerebral function.

That something could be anything, and the bowel involvement suggests maybe it's something you eat-- indeed, the authors suggest the possibility that it is certain foods (grains), casein from dairy, B12 deficiency.

They also list the other exogenous possibilities, including viruses. And then there's the vaccine.

But what's important here is the understanding that the inflammation means it's exogenous. What's important is that the belief that it is exogenous become axiomatic.

III.

"But wait, couldn't bowel inflammation simply be another sign of autism, not the cause? Couldn't the, say, genetic cause of autism also cause coincident bowel inflammation?"

Of course, but as long as the controversy is about the vaccine as cause, then it isn't about bowel inflammation as cause; and as long as we are not arguing about whether the bowel infammation is the cause, then we are certainly not arguing about whether something exogenous is the cause. We are quite likely to simply internalize the something- exogenous- as- cause link.

"You're kidding, right? You think people are that stupid to fall for that?"

IV.

So what do we do? Well, it was one popular recommendation that if the vaccines must be given, they be given separately, not as the combined MMR. This recommendation came right from the lead author, Dr. Wakefield, in a press conference after the study's publication.

It's sleight of hand; blink you missed it. He took it up a step; the controversy has now become whether the combined vaccine is the cause, not whether a vaccine is the cause-- despite none of this appearing anywehere in the study. Wakefield made this the controversy, out of thin air. And everyone fell for it.

"What do you mean? Not everyone believed it." That's not the point, right? The point is to make the MMR the focus, allowing an exogenous case to become our default understanding.

It is so infective, this bias, this groupthink, that the highlighted CDC recommendations about the vaccine which are supposed to allay fears reads:

The MMR vaccine protects against dangerous, even deadly, diseases.

The most common adverse events following the MMR vaccine are pain where the vaccine is given, fever, a mild rash, and swollen glands in the cheeks or neck.

No published scientific evidence shows any benefit in separating the combination MMR vaccine into three individual shots.

V.

"Surely the Lancet tried to do something about this?"

Ha! Don't be ridiculous. They were far too busy studying social justice and peer reviewing "America 2004: voting for a decent global society." I'll spare you the read: vote Kerry.

Ok, that's not entirely fair on my part. In fact, the Lancet and other medical groups/journals/individuals were highly critical of the paper. Not critical of the results, but rather of the fact that Wakefield didn't disclose he had been previously retained as an expert in a lawsuit against the MMR manufacturer.

Before you jump onto that wagon, ask yourself: is that the single piece of missing information that would have revealed this study to be silly? Knowing that would have made them reject the paper? Is not knowing he was connected to lawyers the reason the entire planet missed the lack of connection between his verbal statement "separate the three vaccines" and his own study to which he was referring?

Is money the only red flag for these idiots?

VI.

If I had to come up with a punch line for all this, I couldn't do better than this:

According to the February 8, 2009 edition of a newspaper that is not written by or for doctors, Wakefield made up his findings.

However, our investigation, confirmed by evidence presented to the General Medical Council (GMC), reveals that: In most of the 12 cases, the children's ailments as described in The Lancet were different from their hospital and GP records. Although the research paper claimed that problems came on within days of the jab, in only one case did medical records suggest this was true, and in many of the cases medical concerns had been raised before the children were vaccinated. Hospital pathologists, looking for inflammatory bowel disease, reported in the majority of cases that the gut was normal. This was then reviewed and the Lancet paper showed them as abnormal.

This would be a good place to ask the basic questions, such as

why the Lancet and all journals peer-review manuscripts, but never ask to see the original data itself;
why they allow the public to assume that the journal does scrutinize the original data;
why original data is not public information anyway;
why three idiots and an editor were not able to predict how a study would be used, and ask for the appropriate modifications;
why the presence of "financial conflict of interest" is the only critical test of bias, such that its mere absence earns it the imprimatur of truth. This does not apply to NIH money, of course, which is is free of moral influence: Nihil obstat.

===== ====== ===== The Last Psychiatrist: Bad At Math

how much is this worth

The following story is fiction. Any similarity to people living or dead is purely coincidental.

The doctor was at work doing the usual, which means patients, and a 20 year old hispanic man bursts through the door and right away the doctor knew he was in big, big trouble.

The man wore sunglasses, the kind of one solid plastic band around the eyes that you don't wear unless you're insane. He locks the door behind him and shouts, "if you give me any shit, I'm going to fucking kill you." That was his opening line, the next few lines were derivatives of the same.

He was yelling in English, but at about three threats in he says, "I want a translator--" so he opens the door and the secretary (hispanic) that had come to the door to see what the yelling was about steps in, no, he pulls her in, locks the door again, and goes back to yelling. "You're fucking dead, do you hear me? Fucking dead!"

One other thing: he has a gun.

Putting it together later, yes, there will be a later, the doctor had seen that man, Juan, once before. He had demanded Xanax max dose three times a day, and in the subsequent negotiations it was agreed that as long as the guy could provide clean urines he could get one Xanax half dose a day, along with the other medications. Deal? Deal. So he got a script for 14 days, "come back then and we'll see how things are."

Somehow Juan had taken the 14 tablets as a personal insult, he expected 90, even though it was clear that it was only for two weeks, and however he figured it in his brain the doctor was screwing him. So he came back-- three months later-- looking to show the doctor he messed with the wrong guy. "You think you're going to play me?"

The room they were in was the size of a large closet, about 8x8 square. The door opened inwards, then there's a desk, and then the doctor-- so the desk is in between the doctor and the door. The waiting room is full and it's right outside that door, so everyone can hear the yelling, but no one can see the gun. Not yet, anyway.

The problem, logistically, was that even if the doctor wanted to jump him, he couldn't-- Juan is blocking the door, and the desk is between them. If he comes over to hit him, then they're close, but with that desk in between, the doctor was completely at his mercy.

The other problem, the GIGANTIC problem, is now there's a woman in there with them, and she can't get out because she would have to open the door into herself (she'd end up behind the open door) and then move towards him to get out.

Patients yelling at the doctor to give them Xanax is nothing new-- they threaten, they yell, they posture, and it's all part of the game. The doctor had always played the game respectfully, cool, calm, no anger, and he let them, nonverbally, understand that he respected the power that they had-- if they wanted to, they could kill him-- but that the job is the job, nothing personal, you're not getting Xanax not because I hate you but simply because I don't think it's right. And he let them know that he'd do whatever else he could for them. Sure some people left angry, but they left.

And when they yelled he let them, let them go on for so that they felt like they had delivered their message, and eventually cut them off; ultimately they just need to feel that they chose to let him go, not that they were turned away or rejected but that it was their choice to move on, and when they left that would be the end. It happened about once a week to him and all the other doctors, it's just the nature of the business and there's no billing code for "pissed off xanax seeking guy."

But this guy was different, this guy wasn't looking to get something. This guy came with the specific intention of killing him, he wasn't looking for more xanax or anything else.

And he wasn't psychotic, he was logical, specific-- just very threatening. "You think I'm playing?" "I'm going to tell you what's what." "You think you know me?" Every gangbanger movie cliche, as if he was reading from a script, but if that guy stayed true to his character then this was going to end very badly.

So Juan locks them all in, and she's scared, and the doctor is scared. Because now, with her there, he was completely sure he meant to kill them.   Before she came in, it was between him and Juan only, and he might be able to talk him down, but when Juan brought her in it was clear he wasn't worried about being caught or identified or collateral damage, he just wanted to kill.

So he yells for about 30 seconds (it felt like an hour) and then the doctor tells him that perhaps he can get him some Klonopin, which is a lot like Xanax. The Klonopin was incidental to the argument, but he figured that if he could get this maniac to focus on something concrete, turn it into a treatment or at the very least a transaction, in which he could be "given" something, the guy might back down just enough to not kill everyone.

But the problem was the woman. She was scared but also... irrational. Would she try and run? Would she try something stupid? Was he going to kill her, too? He had to get her out.

So the doctor turns to Juan and says, "but I need your insurance card to make sure I can give you Klonopin." That was a lie, but it was a distraction, turn the focus to something else.    Juan gets his wallet out muttering, "he wants my card now, my card, this fucking (something) wants my card." And he gives it to the doctor, and the doctor hands it right to the woman and says, "I need a copy of this immediately. Immediately." She hesitates, she's unsure, she moves towards the door slowly but Juan lets her pass. Thank God, he thinks. It's going to be okay.

Wrong. As soon as Juan closes the door behind him, he goes ballistic. It was like he remembered what he was there for. "You fucking [this], I'm going to fucking [that]!" and etc. Whereas before he was waving the gun around, now he kept his arm locked, gun pointing towards the floor. He's still yelling, cursing, threatening. The gun is there and it's pointing down and it's simply waiting for him to decide to raise it.

Again, even if the doctor could disarm him, he can't because of the desk. He can't throw anything, there's nothing else on the desk. He can't run. If he stands up, he'll get shot in the chest. If he ducks down, it forces Juan to lean over the desk, which means he'll get shot in the back of the head or the spine.

This was the plan: turn to the side and let him shoot him in the shoulder or arm.

What did he think about? He thought about his kids, how sad they'd be that their father was dead. They would cry.   He thought about how this nut would eventually get caught and the kids would have to face the man who did it and listen to his words and the words of everyone else. The kids would have to look around at an insane world that tried to explain everything with lies. And then they'd have to go home and grow up. "That's life," someone would tell them, because it's true and that helps.

He also thought about how stupid this guy was, how terrible he was at valuing things, he had decided that his life was worth throwing away over... what? He wasn't stealing his car, there wasn't anything of value at stake. Xanax? He could have gotten it anywhere else, easily, anytime. Revenge? It wasn't like the doctor had raped his sister, he had just not given him something. But somehow in his calculus this grudge was worth carrying for three months, worth killing someone over, worth 25 years in jail. This wasn't psychosis, this was a man who was bad at math.

The plan is to give him the shoulder, take it in the shoulder, and not turn, not go down.

Then the woman comes BACK. What caused this woman to come back is unknowable, but she opens the door and it bumps him because he's in front of it. So he turns around to see who's coming in and he grabs the paper out of her hand and he sort of flings it at the doctor.

But everything is different now, because the door is wide open, and everyone in the waiting room can see them.

So the doctor, as calmly and with as much authority as he can muster, looks at the paper and says "ok, I can give you 30 tablets of Klonopin with this." He tried to make it sound like that was what they had been talking about the whole time, a treatment, a transaction. It wasn't about the doctor, it was about the pills.

Juan reflexively says, "no, Xanax," and the doctor responds, "no, all I can give you without a urine (drug test) is Klonopin," and Jaun says, "I want 90 of them." And the doctor says, "only after the urine."

Whatever calm exterior he displayed was not mirrored on the inside, and while he was trying to show steady penmanship he made a mistake- and he wrote Xanax instead of Klonopin.   It just came out. So now Juan sees the doctor writing that, and the doctor has to decide if he was going to give it to him that way or not.   But if the reason he was still alive was that he had turned it from something personal into a treatment, then handing him the Xanax was an admission that it was, after all, not a treatment but a stick up. And maybe that would remind Juan that the doctor had screwed him the first time. So the doctor says, out loud, "dammit," tears up the script and rewrites it. Doing the job correctly.

Juan took it, made a few more threats, and left. 20 minutes after that the police finally came, and while they were there he called the clinic and said he was coming back to kill the doctor because he only got 30 tablets. A man who is terrible at math.

When the doctor went back to see the patients who stuck around, all of them, men and women, told him the same thing: "Yo, man, I had your back, if anything happened, I was going to bust in here." Of course they would have.

What's unsettling, however, is that Juan had been in the waiting room for an hour before the doctor even got there, muttering to other people that he was going to "fuck him up." But no one said anything.

There's not much more to the story, except that the doctor went home, felt a little shaken, had a drink or three, debriefed with some people and not with others, and eventually 3am came and he went to bed. And when he woke up it was gone, merely a memory, it all felt like it happened a decade ago. That's life.

===== ====== ===== The Last Psychiatrist: Bait And Switch: Surveillance Movie Review

I saw the movie Surveillance.

As bad as it was, the movie wasn't the problem. The problem was the trick they used to get me to see it.

I spoil nothing in telling you that if you can't guess the entire plot in the first nine seconds of the movie then this review won't help you because you probably have had a stroke.

It is about two masked serial killers, the kind whose main ability is to remain totally calm the way no one ever is even when asleep, while their victims cry, stumble, make astounding errors in judgment and never, ever fight back.

Two FBI agents travel out to interview (the only three) surviving witnesses of a 6 person gore fest mediated by stupidity. The agents place the three stereotypes-- a cop, a junkie, and a little girl, what else-- in separate rooms, and set up cameras to monitor all three simultaneous interviews. The idea is that witnesses are unreliable, or, as the director put it in an interview-- and you're going to want to sit down for this-- versions of the truth change when you are being watched.

I know, I know.

So why tell this story? Why should the audience want to see it? The director explains:

I haven't seen a serial killer film the way I want to see a serial killer film and I want to confuse people about what good and bad look like. I want to break that 'book by its cover' mode and play with that."

Because no one ever suspects "the guy you least suspect."

II.

The problem is we aren't watching it because we think the director made a new kind of serial killer movie. We aren't even watching it because we like serial killer movies. We are watching it because the director is David Lynch's daughter, and David Lynch himself is the executive producer.

We're hoping this is going to be like Twin Peaks II.

"But the funny thing is, he had nothing at all to do with it," Jennifer Lynch says.

It's your movie, I get it. I know it's hard to come out from a famous parent's shadow and find your own voice, and I'm sure she doesn't want people assuming this is a David Lynch movie, but can you blame us? It's not like anyone makes any attempts at hiding David Lynch's involvement. In fact, they take extra special care to bludgeon you in the face with it.

Here's how a woman who wants to be her own kind of director with her own creative vision distances herself from her father: first, she would change her and David's name to pseudonyms or hide them altogether and make the movie posters as different as possible:

posters different.jpg

She would cast people who are as un-David Lynch as possible, who invoke in your imagination completely different kinds of movies. Actors who have never even seen a David Lynch movie, let alone been in one. As an example, she would be very careful to not cast Bill Pullman and Julia Ormond because, well, you know.

bill pullman.JPG

She would be careful not to shoot scenes or images that call to mind any of her father's work:

fbi caught on tape.JPG

or choose to feature objects that have symbolic importance to her father:

guess which movie I belong to

And putting a haunting image of a disfigured/masked face coming out of the darkness; ethereal sounds, inaudible whispers-- all those are completely out of the question

Whose movie did she think we were going to see? I'm not saying that Jennifer Lynch has to make movies like David Lynch; nor am I saying I expect her movies to be like David Lynch's, except in the single circumstance that she goes out of her way to tell me it is a David Lynch movie, and make it look like a David Lynch movie.

Which, again, is fine-- but then actually make a David Lynch movie. No. Instead, she doubles back and makes the most obvious, conventional movie possible given the budget. This movie is more linear and predictable than The Honeymooners.

Again:

"But the funny thing is, he had nothing at all to do with it," Jennifer Lynch says.

I can see that. That's the problem.

In fact, the key stylistic difference between the two Lynches is that Jennifer shoots careful, focused scenes that are incomprehensibly irrelevant to the story.

top secret.JPG

At first I thought such shots were simply mistakes? but then I read her description of the two killers:

How did you want to see a serial killer film in ways we hadn't seen a serial killer film before?

JENNIFER ===== ====== ===== The Last Psychiatrist: "Because I Said So"

I have written endlessly about how language controls psychiatric thought, and that it will be impossible for psychiatry to progress while semiotics trumps science. Here is a recent example:

In the Oct 2006 JCP, there is an article about the efficacy of Depakote ER for acute mania.

As I read the introduction to this useless paper, I get kicked in the throat by this:

"Currently approved treatments of the acute manic phase of bipolar disorder can be categorized primarily as mood stabilizers (e.g. divalproex sodium, lithium, and carbamazepine) or as atypical antipsychotics (i.e. aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone.(5)"
Note carefully that the authors have taken a set of medications and artificially divided them into "mood stabilizers" OR "antipsychotics." Ok, well, wouldn't it be great if reference 5 actually justified this? Using data or logic? Well, it doesn't.
But the damage has been done. Unless you have a computer with FIOS and three monitors and are reading every reference, a quick skim registers that there is a reference, which you assume has been checked, and move on. In fact, the authors here don't even feel that a reference is necessary-- everyone knows what a mood stabilizer is. It's too basic to even reference.
So, is there any reason that seizure drugs are "mood stabilizers" (read: prophylactic) while antipsychotics are not? For antipsychotics, is there anything about their pharmacology, half-life, color, or pill size that a priori exclude them from the "mood stabilizer" category while including the seizure meds?

The artificiality of the terminology is confirmed when you actually look at the data: the only drugs listed here which actually are "mood stabilizers" are lithium, olanzapine and aripirazole (over 6 months).

A study may eventually show Depakote is a mood stabilizer after all, but that's not my point. My issue is that in the absence of data or logical necessity, how can we take an arbitrary set of names and make unjustified deductions?
This is the semiotic trap of psychiatry. It doesn't actually matter what the data says (e.g. Depakote is not a mood stabilizer, Zypexa is), what matters is the language, the categories. This isn't science. Just because there are graphs and chi-squareds, doesn't make it science.   There's no science here at all. At best it is linguisitics. At worst, propaganda.
I'm not saying they are lying. It's worse than that. It's the structure of psychiatry. It's a subtle manipulation of reality to make people believe what you "already know" to be true. They are trying to convey a perspective, not report a finding. For example, later on the authors try to make the point that higher levels correlate with efficacy, but go too high and you get toxicity:

One analysis noted that serum valproate concentrations between 45-125 ug/ml were associated with efficacy, while serum valproate concentrations > 125 ug/ml were associated with an increased frequency of adverse effects. 19
This isn't what reference 19 says, exactly. What it says is that 45 is a pivot point; below it is not as good as above it. But it doesn't say that higher and higher levels give you better and better efficacy. What makes the omission of this rather important clarification all the more perplexing is that reference 19 was written by the same authors as this article.
But the damage has been done, again. Now you think you have read a statement in support of what you already assumed to be true. So you push the level.
You may argue that I am misinterpreting the author's words, that he never implied that efficacy had a linear relationship with level. Ok: prior to reading this blog, did you think that there was? Where did you learn that? Did you pull it out of the ether? No-- you skimmed articles like these that left you with half-truths, and never questioned it because everyone knows this already.
Let me show you what I mean. Here's the relationship of the Depakote level to maintenance treatment:
Higher serum levels were modestly but significantly correlated with less effective control of manic symptoms in a maintenance study (26). The study therefore supports a somewhat lower serum level range for maintenance treatment than for treatment of mania.
Did you know that? That the efficacy decreases as the level increases? I'm not asking if you believe it, I'm asking if you had ever heard it. Because if the answer is no, then there is something very, very wrong with the way we convey our knowledge. *

-------------------
*Contrary to the opinions of former girlfriends, I am not an idiot. I can plausibly explain this odd finding: the most manic patients got higher and higher doses, so the least responsive ended up getting the highest doses and levels. So it looks like higher levels were associated with decreased efficacy, when really the highest doses went to the sickest people. Ok, good explanation. But this supports my earlier point: you can't take something which requires a post hoc justification and use it to make a leap in logic to conclude something else.

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===== ====== ===== The Last Psychiatrist: Beer Goggling Isn't Natural and Being A Good Looking Girl Sucks From 9 To 5

Who's hot, and who's not? Ok-- who's dumb and who isn't? Were they different?
Now-- who knows way to evil power source?

An internet meme spreading through the blogosphere: "Eyes Can't Resist Beautiful People." I took the extra step of looking up the actual scientific article the news report cites, just in case there was more to it (and of course there was.)
A study discovers that when heterosexual undergraduates are shown pictures of random undergraduates, they have increased attention for pics of attractive opposite sex people. So, guys look at hot girls, and vise versa. Not exactly surprising.

y-axis is time spent looking at the pic

But more interesting was the finding that, even when the subjects were "sexually primed" (told to write out a sexy story) the increased attention was only to the really attractive people. There was no increased attention to average looking opposite sex pictures. In fact, attention to the average looking people was no different than the attention to same sex pictures.

Additionally, people in "stable" relationships (whatever that means-- these are undergraduates, remember) did not have this effect. Perhaps they were "satisfied," but these tests are really about unconscious preferences. The fact that there was no significant draw to the attractive people (over anyone else) speaks to, in my opinion, an innate monogamy in humans.

But don't think these pussy whipped losers (kidding!) don't have instincts-- they're just different than unattached people: committed people's attention lingered on attractive members of the same sex.

In other words, rivals.
So while there's a drive towards monogamy, there's also an assumption/fear that your mate might not be.

So this implies that the person's state-- "where your head is at"-- affects not sexual preference, per se, but the priority of your attention. Single people are looking for sex; couples are looking out for rivals. Consider that you only have a finite amount of attention. In either case, your attention is focused on the most attractive, not distributed proportionally depending on how attractive the person is.
But what are we thinking about the person we are looking at? Once we've assessed their attractiveness (and, if a rival, attractiveness relative to our own), what do we think about their character?
In another issue of the same journal, 20-somethings were asked to decide if the success of photographed individuals was due to luck (looks?) or ability. As you might imagine, women attributed good looking women's success to luck, and less attractive women's success to ability; but thought good looking men succeeded because of ability, not luck. Men did the exact same (respectively): good looking men succeeded through luck, good looking women through ability.

This is called the sexual attribution bias, and it's negative, not positive-- i.e. it is specifically about devaluing the good looking rival, not about making correct judgments about the less attractive.   And it depends nearly entirely on what extent you think you are more or less attractive than the other person.
So while we devalue a rival's abilities relative to their looks, we are unconsciously aware of their actual attractiveness (relative to our own.) Consider that pejorative and devaluing terms for women-- airhead, bimbo, dumb blonde, bitch, slut, etc-- reflexively connote physical/sexual attractiveness, at the expense of intelligence, etc. "That girl is an airhead, I can't believe she can read, let alone work at Goldman Sachs. But I'm not letting her out of my sight or near my boyfriend..." (Interestingly, pejorative terms for men have almost no attractiveness implication: jerk, arrogant, idiot, loser, etc. Some terms, like meathead, frat boy, imply stupidity and aggressiveness, but not attractiveness, per se.)
What it implies, of course, is that attractive (relative to others) women employees may have a more difficult time in the workplace if their coworkers, and especially bosses, are also women.

(Here's another internet meme I dealt with, about sleep deprivation and moral judgment. Also, note carefully the fourth comment, by "Anonymous.")

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===== ====== ===== The Last Psychiatrist: Being The Main Character In Your Own TV Show Is Sort Of A Delusion

Two psychiatrists, believe they have discovered a new, YouTube generation, delusion: believing you are in a secret reality TV show.

The article describes cases of people who believe they are secretly being filmed.

"I realized that I was and am the centre, the focus of attention by millions and millions of people," explained one patient, an army veteran who came from an upper-middle-class upbringing."My family and everyone I knew were and are actors in a script, a charade whose entire purpose is to make me the focus of the world's attention."
The belief that they are being filmed certainly gives the person a sense of importance, or worth independent of and beyond the mundane life he lives in. In other words, it allows for an inflation of identity without actually having to do anything.   Call it grandiosity

The patient added that he planned to climb to the top of the Statue of Liberty, and if his true love were waiting for him, the puppeteer strings would be cut. If she failed to show up, he would jump to his death.

Grandiosity is one explanation, but I submit that the important part of this delusion isn't the filming, but the "puppeteer." The delusion isn't about self-importance, but rather an explanation for powerlessness. I am being manipulated by the outside. There's nothing I can do.

Consider that a delusion which enhances your importance might not be one you'd want terminated; but these cases have the termination of the delusion built in.

In "reality" (ha!) such cases are cognitive metaphors for maturity. Only when you gain sufficient self-awareness and autonomy can you break away from the artificial, manipulated reality of adolescence.

"But these guys are 30 years old!" Exactly. Real adolescents don't need a delusion to tell them they're powerless. But a 30 year old should be dealing with intimacy vs. isolation, but instead they're stuck back at identity vs. role confusion.

The delusion is the protection, not the empowerment. It says, "don't worry, you haven't accomplished anything because the producers haven't put that into the script yet." Ultimately, this YouTube delusion is the result of a fleeting awareness that you cannot choose your identity unless you back it up with actions-- that actions are identity.

When a narcissist has this awareness, he has two choices. He can retreat into a protective delusion, such as this one; or he can convince-- read: force-- someone else to accept his identity even in the absence of actions. "I am a tough cop! Well, maybe not actually a cop, but if something went down in this mall, I could be like a cop, and that's just as good!"

You do not want to be the person the narcissist tries to convince.

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===== ====== ===== The Last Psychiatrist: The Biggest Dick Ever
A true story about what happens when words lose their meaning.

I'm in the gym, there are only two other people: Devastator, and The Kid. Devastator is black. You might guess why that will soon be relevant.

Out of the corner of my eye, I see The Kid is stalking me, looking to talk to me, to anyone. I see this everywhere, people like a bomb on a hair trigger, the slightest contact explodes a full attempt at connection. I sympathize with women on this, they have it particularly bad. If they even let on that they are aware the guy is in the room, he takes it as a strong invitation to come over and talk about himself.   They're everywhere, bookstore stalkers and coffeehouse predators, empty, hollow, looking for something to fill them up, that something is almost always a woman. At 24 it's sad but normal, at 34 it's sad but dangerous.

So there he is, weaving and hovering, looking for an in with me. I don't like people, I don't like being approached by people and truthfully I look like someone you'd never approach without air cover. I look like a mugshot, I look like I relapsed a week ago, when I walk past a church unseen dogs bark at me and when I walk into a store they call Homeland Security. Yet still, everywhere I go, strangers cross freeways or walk through glass to get to me, for what? To inform me that Karl Rove wants to destroy welfare or all these bitches care about is money or "oh my God, you look just like my ex-boyfriend's Dad!"   Broken people have a 6th sense for other broken people, I guess.

I finish what I'm doing, which is nothing, and he pounces. "That guy..."

"What guy?" I say it to make sure that the only guy he could be asking about is not standing behind me.

"The big guy. The big...big guy." So much for new post-election open dialogue about race. "He was huge--"

"Oh, yeah?"

He puts his hands out, palms facing each other, and uses it to italicize each word. "Biggest dick ever."

"Oh," I say.

"Huge. The biggest dick ever."

So now I have half an instant to decide whether this guy made an assessment of Devastator's character based on some personal experience; or whether he is falling back on stereotypes about narcissistic weightlifters and is asking me to bond with him over a shared worldview? Or is he going with a racist perspective?--

Or, did the The Kid see Devastator in the locker room and is now compelled as an instrument of natural selection to tell me that he has the biggest dick ever? And if so, then I'd have to figure whether The Kid has not seen many dicks and is just mystified that dicks can get so big, or if he isn't in fact gay-- or thinks I'm gay-- and this is the best he could come up with as an opening line? Or is he so charged by the guy's overall size that he is imagining that because he's huge and black that he must have a gigantic penis?

So I don't know which one he means. Whichever I guess only indicates my own prejudices about guys, black guys, and dicks. No matter what I guess, if it's wrong he's going to think I'm a dick.

Big dick. Why is dick a preferred insult? I get what pussy means, and at least asshole is anatomically logical, but calling a guy his most precious organ-- what?   A girl calls you a dick when you're overly sexually aggressive, ok, I'm copilot, but what do you say when a guy calls you a dick? "You don't know the half of it!"

He spares me. "All I did was ask him how long he'd been training, you know, to get that big, and he blows me off! 'Don't talk to me, not when I'm lifting.' "

"Don't take it personally," I say, "some of these powerlifter guys are overly focused. I don't know that guy, but I know what you're talking about, I know the mentality." Then, to discharge the anxiety he's feeling about it all, I smile at him and joke, "now get away from me, I'm lifting."

He laughs, but I instantly regret saying it. Now he probably thinks I'm a big dick. Which is good or bad for me depending on who he tells next.

II.

Twenty minutes later I am in the locker room, and it happens: Devastator comes towards me. Completely naked.

"Big dick, huh?"

He stops inches from me. "Big dick?" He's pissed off, and I realize immediately the Kid was right all around.   I've only ever been assaulted with one other gigantic penis in my life, when I worked at the VA and a schizophrenic on the cardiology unit came at us firing in semi-automatic mode. How that nut got hold of a Do Not Resuscitate form I'll never know, how he got hold of a stapler is less of a mystery, but he was walking and ejaculating and stapling the form to his bare chest, "I'm DNR-C, I'm DNR-C!"

So now I'm back at the same question with different assumptions, is he angry because we talked about him being a dick or talked about his dick? Surely both have happened to him before.    Is he a narcissist or a homophobe?

I guess the former. I take my right hand and rub my left ear, I do this to get it up in case something happens.

Something happens. He suddenly slams into my chest, pushing me back, I'm already against the lockers so there isn't much room for me to go but I hit it hard. The wind gets knocked out of me. Oh, great, I think, I'm back in 9th grade. I hammer my fist into the side of his head above his ear.

To my amazement, he drops to the floor, out cold.

Now what, I think.

III.

There are soon/instantly six other people in the locker room, tending to and restraining Devastator, and through a process of semi-apologies, semi-praise for my strength, semi-acknowledgment of his prior neck injury and current self-respect, everyone agrees that everything is cool. We shake hands, he pulls me in for a hug. He is still naked. Everyone grabs their clothes. Two trainers and I head out.

When we are well out of the locker room, one of the trainers glances behind and snickers. "What a dick," he says.

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===== ====== ===== The Last Psychiatrist: Biology Is Destiny
Palm up. Measure your index finger (2D) and ring finger (4D) from bottom crease to tip of finger (not nail).

Question: does life begin at conception? Why, or why not?

I. Nature:

The study looked at 49 male futures traders (high velocity, high leverage). The mean age was 27, the mean annual income about $500k (range -$4000 to $8M.)

The study found that low 2D/4D ratios (long ring fingers) were highly correlated to higher profits; the ratio also predicted the ranking of the traders based on of profits.

2. Nurture:

Chronological age was not a factor in profits, though years of experience was.

So "nurture"-- years of experience-- and "nature"-- the prenatal testosterone exposure, which causes long ring fingers-- both affect performance.

The study found that experience boosts profits by 9 times over inexperience; low 2D/4D (long ring fingers) ratios boost it 11 times over high 2D/4D ratios.

Having lots of experience only barely made up for having a higher finger ratio (short ring finger).

The same authors had done a prior study with traders, and found that levels of morning testosterone (which fluctuates both intraday and interday) predicted that day's profits; the higher the am testosterone, the higher the profits for that day.

Taken together, some people may have a biologic advantage to making money in futures trading; this biologic advantage may be greater than having experience.

II.

Other studies have found relationships of 2D/4D ratios to everything from homosexuality to osteoarthritis.

I don't know why the 2D/4D ratio (intrauterine testosterone exposure) have an effect on such things. What interested me about the paper was this:

The financial markets are made up of many sectors and types of trading, and each of these may select for different biological traits. But if markets select traders on the basis of their profitability and their occupational preferences (36), then low-2D:4D traders will continue to influence asset prices and equilibria in some of these sectors. Contrary to the assumptions of the rational expectations hypothesis, financial market equilibria may be influenced as much by traders' biological traits as by the truth of their beliefs. (emphasis mine)
What the authors suspect-- and what seems obvious once you say it out loud-- is that not only are certain people better suited for certain work or environments, but that they then change the environment itself so that they are the ones best suited for it.

A ha! the system is stacked for a certain group, against another group!

But it's no more stacked against us than our technological world is better suited to electrical engineers. This is why we have an economy that uses money; we can hire someone who is suited for that work, to act as our agent.

But what about things that can't be bought?

III.

If philosophy and ethics attract certain types of people, then those people go on to further alter the answers to ethical questions. It occurs to them to ask certain questions and not others; and those with a differing perspective or mindset do not naturally possess the equipment that allows them to join in the discussion. What do you think happens to ethics?

Diversity of opinion is an illusion. The choices "it is ethical" and "no, it's not ethical" are actually of the same form, they come from the same kind of brain. For example, they both presuppose that the question is an ethical one, and not a logical one, or a practical one, or even a religious one, or a mechanical one, or a mathematical one, or a...

But once a field is dominated by a group, that group reinforces its groupthink. It decides the form of the discussion. For example: the question for everyone is about ethics. Those who think it is, say, a logic problem are forced to remold their logical argument into a quasi-ethical one, just to be able to participate in the discussion. And their intellectual compromise is thus both less ethical and less logical. This reinforces for the ethicists that their perspective is the rigorous one. When you hear someone speaking broken English, you assume you're smarter than him; it sounds like he's dumber than you.

These compromisers die and are never heard from again. It is a bat talking to a bumblebee about what color a flower is.

A student of history knows that history repeats; what is different is the people living it, and how they frame their present.

Since this dialogue is absolutely impossible, then the only kind of change that is possible is a paradigm shift.

Paradigm shifts cannot occur without a change in biology: it requires a completely new generation of human beings.

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===== ====== ===== The Last Psychiatrist: Bipolar Rates Are Increasing As Long As You're Willing To Call Everything Bipolar And Defy God's Will
Do you dare defy the Will of God?

In 1994, there were 20,000 visits for pediatric (under age 19) bipolar disorder. In 2003, the number was... 800,000. The diagnosis, therefore, was 25/100,000 in 1994, and now it's 1000/100,000. In other words, 1% of the population.

To compare: for adults the rates were 905/100,000 in 1994, to 1679/100,000 in 2003. In other words, 0.9% up to 1.7%.

I've heard this justified as a step forward. While "visits" isn't the same as incidence or prevalence in a population, it makes sense as a proxy. The adult rate is about 1-2%, consistently. Bipolar was severely underdiagnosed in 1994, and it's better diagnosed today. Since bipolar is a biological disorder with a strongly heritable component, it only makes sense that the child rate should be the same as the adult rate, assuming good diagnostic skills. So the diagnosis rate has simply risen to match the adult rate.

The only problem is this: in 2003, 2/3 of the children visiting were males. But 2/3 of the adults were females.

So you have some options:

The male children have a disorder that is actually different than the adult females have, i.e. one of them is not bipolar.
The male children with bipolar got cured during puberty.
Bipolar disorder turns boys into women sometime around age 19, obviously using the power of Satan.

The ridiculousness of this increase in diagnosis is only exceeded by the potential harm such an increase is actually causing. Forget about the safety or lack of safety of bipolar medications in kids, which is worrisome enough. A problem few seem to want to talk about is the impact of a bipolar diagnosis on a person, for the rest of his life. Let's say, for the sake of argument, pediatric bipolar is overdiagnosed. Then all those people who were misdiagnosed are, in fact, not bipolar; however, they have no way of ever finding that out. They have to carry this with them for the rest of their life. When they're 30 years old, and they're asked on routine checkup if they've ever had a psychiatric diagnosis, they have to say, "well, pediatric bipolar, but I think that's not right." Sure it isn't. When that 30 year old guy has kids, and those kids grow up, they'll be asked, do you have a history of major psychiatric illness in your family? Hmm. "Maybe bipolar... but my Dad told me he thinks that wasn't right." Oh, ok. Did your Dad have a temper? "Well, he did yell a lot when he was mad." I see. Did he go without sleep? "Oh my God, when we were kids-- lots of times." Then it's settled.

If pediatric bipolar is being accurately diagnosed, then either psychiatrists are now more sensitive to its detection-- a unlikely possibility since the diagnosis has been around for a long, long time-- did we suddenly develop a better test for it? Or else something has changed in the world to cause it to be more frequent (a toxin in bottled water? MySpace? Iraq?)

Early treatment of bipolar-- let's call it the "real" bipolar-- doesn't slow down the progression of the illness. It helps you today, but it doesn't change symptoms 10 years from now, they way aggressive early treatment of diabetes actually prevents physical pathology from worsening. So it may be worth, oh, I don't know-- conservative management?

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===== ====== ===== The Last Psychiatrist: Birth Order: Are First Borns Always Older Than Their Siblings?

Yes, but it doesn't mean younger children can't be older than someone, too. Everyone's a winner!
That said, according to USA TODAY and Science Magazine the oldest kids are the smartest. Let's assume that this is correct. What's the reason?

The most common explanation is "resource dilution:" the oldest usually gets the most parental resources. In any given day, the oldest receives more attention than any of the sibs. The more attention you receive, the more you develop. The attention (more reading, more activities, more conversation) is supposed to give the oldest kid the emotional resources to grow.
That's fine, but it doesn't explain why only-children aren't the smartest, for example. (Common answer: the parents of an only child didn't want more children because it took time away from themselves; so the only-child actually receives "less" attention than other kids in other families. Maybe, but it can't be true for all such families. (Can it?))
But I favor a different explanation.
First, oldest kids get parentified: "go watch your brother and sister!" "Make sure this baby doesn't roll!" "Look, I know you're only five, but I can't get up right now, do me a favor and go into the kitchen, get out the lasagna pan, set the upper oven to 450, chop up the garlic and I'll be there in a minute." Oldest kids may not be smarter, they may just have had to grow up faster; they have to learn to think fast, improvise, etc. This might explain USA TODAY's survey of CEOs: 50% were first born, while 20% were last born.
But second, there's this: "you idiot! you chopped the garlic with a steak knife!?"

You learn fast, lessons your younger sibs don't learn as early in life. And, specifically, you learn a) what adults "do" (because you're often expected to replicate it); b) that you are always under scrutiny-- so perform, don't bother trying to hide; c) that you are under more scrutiny than your sibs-- in other words, that they are "special." Not better, but singled out for more responsibility, more scrutiny than others. For some reason, you are different.
Here's something interesting: more than likely, you are attempting to frame this post in terms of your own childhood. Were you the oldest, youngest, what happened, etc. Why doesn't it occur to you to frame it in terms of your own children?
If you're a parent of more than two kids, ask yourself the following: who do you yell at the most? Would you trust your youngest today to do things you trusted your oldest to do at that same age (e.g. watch a baby?) When you need a kid to do something for you, who do you ask?

I know you'll have "reasons" why you pick the first, but the important part is that for whatever reason, you are picking the oldest.
Identity comes easier to the oldest born, because it is reinforced (positively or negatively). "You know better, "you're supposed to," etc. It's pretty easy to see how narcissists are almost always the oldest child. (And borderlines the youngest, or only.)
Depending on why they get more scrutiny and more responsibility, they develop differently.
Maybe by the time the parents get to the third kid they're too tired to uphold the same level of performance-- so it is that the youngest seems to get away with more; maybe the parents realize they were too tough with the first. In this case, it's too late for the oldest, but the benefit to the younger ones is greater. Maybe they thus get more positive attention and less punishment or control. So maybe they become artistic, or pick a career that's unusual.

But sometimes a relational pattern is established, like dating the same kind of guy over and over. A pattern develops, where the oldest "never does anything right" (because he's expected to do what would never have been expected of the youngest) and parents are repetitively in an emotional state of anger or frustration. Soon, that's how they relate to each other; the oldest on the defensive, or trying to perform, the parents on full alert, ready to go insane. Even when the kid grows up and stops making such "stupid mistakes," the pattern is already firm: the parents relate to him by leves of anger and frustration.
The result in this situation is that the oldest goes on to succeed-- amazed, really, at how easy the world is and how little is actually expected of or necessary from him, in comparison to what went on at home-- but is simultaneously bitter, resentful of how easy it is for other people to be happy when they want to be, despite their lack of successes. These people can easily become abusers (especially emotionally) ("I hate your emotions!"); they can become alcoholics ("I hate my emotions!"); insomniacs ("I hate that another day has passed and I have done nothing of actual consequence, nothing, nothing, nothing.")
(For more on prenting/developmental issues, search the site for "parenting.")

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===== ====== ===== The Last Psychiatrist: Borderline

Narcissism- what I believe to be the primary disease of our times-- is one side of a coin. The other side-- the narcissist's enabler-- is the borderline.
If the analogy for narcissism is "being the main character in their own movie," then the analogy for borderline is being an actress.

Note the difference: the narcissist is a character: an invented but well scripted, complete with backstory, identity. The narcissist is trying to be something-- which already has a model. Perhaps he thinks himself an artist type, or a tough guy, or the type interested in spiritualism, or like the guy in the Matrix. Types, characters. The borderline is no one: the borderline waits for the script to define her.

Her? Yes. Narcissists are mostly hes, and borderlines hers. (Not always, sure.)

The classic description includes: intense, unstable relationships; emotional lability; fear of abandonment. The borderline has no true sense of self.

Ironically, the borderline is a borderline only in relationship to other people. The borderline has a problem with identity only because other people in the world have stronger identities. Your Dad wants you to be one way, so you do it. Your boyfriend wants a different woman; so you do it. Your husband wants something else; so you do it. Who the hell are you, really? You have no idea, because you are always molding yourself based on the dominant personality in your life.

This si done mostly out of fear of abandonment: if you don't "be" the person they want, then they'll leave you, and then what? (Borderlines don't end relationships-- they end relationships for another relationship.)

The narcissist creates an identity, then tries to force everyone else to buy into it. The borderline waits to meet someone, and then constructs a personality suitable to that person.

If a borderline is dating a guy who loves the Dallas Cowboys, then for sure, she will love the Dallas Cowboys. If, however, she breaks up with him, and then dates a guy who loves the Giants, then she'll love the Giants. But here's what makes her a borderline: she will actually believe the Giants are better. She's not lying, and she's not doing it for him; she actually thinks she thinks it's true. Everyone else on the outside sees that it is obviously a function of whom she's dating, but she is sure she came up with it on her own. And she's not play acting: at that moment that she believes, with every fiber of her being, that the Giants are better.

Here's the ironic part: if a borderline was shipwrecked on a desert island with no one around, she'd develop a real identity, of her own, not a reaction to other people. Sorry, that's not the ironic part, this is: she'd become a narcissist.

The bordeline has external markings of identity: tattoos, changing hair colors, clothes. You may recall I said almost the same thing about the narcissist: the difference is, of course, the borderline changes her image as she changes her identity-- in other words, as she cahges the dominant personality in her life; but the narcissist crafts a look, an identity, which he then defends at all costs: "I would sooner eat fire ants than shave my mustache." Of course. Of course.

All those silly movies about a woman moving away, or to the big city, and she "finds herself:" that's a borderline becoming a narcissist.

If you look back on past long term relationships you've had, and are completely perplexed as to what on earth you ever saw in each of those people that kept you with them for a year; well, there you go.

This is why narcissists marry borderlines, and not other narcisstists. Two narcissists simply can't get along: who is the main character? Meanwhile, two borderlines can't be with each other-- who supplies the identity? The narcissist thrives with the borderline because she provides for him the validation that he is, in fact, the lead; the borderline thrives with the narcissist because he defines her. And, as she will tell you every single time, without fail: "you don't know him like I do." Everyone else judges his behavior; but the borderline is judging his version of himself that she has accepted.

Go back to my white high heel shoes example. The narcissist demands his woman wear white high heel pumps not because hem ay like them himself-- he might or might not-- but because he is the type of man that would be with the type of woman who wears white pumps. He thinks he's the sophisticated, masculine man of the 1980s, so she damn well better be Kim Bassinger from 9 1/2 Weeks. Blonde hair, white pumps. She could weight 400lbs, that's not the point (though it will become one later.) So she wears the shoes, and starts to believe she likes them, starts to believe that she is that woman. He reinforces this with certain behaviors or language towards her (he'll open the door for her, push her chair in, etc. You say, "well, what's wrong with that? Nothing, except that he ALSO beats her when she doesn't wear the shoes.)

It's almost battered-wife syndrome: what keeps her with tat maniac is that when he's not beating her, it seems like he is actually being kind to her, so great is the difference between being beaten and simply not being beaten. Meanwhile everything he does wrong has an external explanation: it was the alcohol, he's under stress, etc. And she's doing this rationalizing for herself, not for him, because it is vital to her own psychological survival that he actually be who he says he is, that he actually have a stable identity that things happen to, because her identity depends on his being a foundation.

That's why the therapist has to maintain such neutrality, consistency in the sessions. It's not just to avoid conflicts; by being the most dominant (read: consistent) personality, the borderline can begin to construct one for herself using the blueprints of yours as a guide.

If the borderline sounds like a 15 year old girl, that's because that's what she is. The difference, of course, is the actual 15 year old girl is supposed to be flaky, testing identities and philosophies and looks until she finally lands on the one that's "her." But if you're 30 and doing that, well...

--------
(BTW, if you want to understand the mystery of women's addiction to shoes, here's my take: shoes are the article of clothing that represent possibility. Each shoe is a different look, a different character, and she can select "who" she wants to be that day. You might not notice the difference, but she feels it. This is not borderline-- it's normal, but it's normal because the shoe changes and the rest of her doesn't.)

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===== ====== ===== The Last Psychiatrist: Breast Implants and Suicide

I'll give you the punch line first:   In each of the Danish, Swedish, Finnish, American, and Canadian studies, appx. 0.4% of breast implant patients killed themselves, representing a two to threefold higher risk than the general population. In some studies, the risk of suicide was increased to 1.5 times for any type of plastic surgery. Getting implants over 40 may also be a risk for suicide.

2761 Danish women who got breast implants from 1973-1995 were compared to 7071 women who got breast reduction, and 11736 who were considered controls. Median age was about 31.

14 (0.5%) breast implants committed suicide, 3 times more than expected (i.e. standardized mortality ratio=3).   7 of them had been previously psychiatrically hospitalized. 220 (8%) of all implants were psychiatrically hospitalized.

22 (0.3%) breast reduction committed suicide, 1.6 times more than expected. 6 of them had been previously psychiatriically hospitalized. 329 (4.7%) of all reductions were previously psych hospitalized.

0 controls committed suicide. 96 (5.5%) were previously psychiatrically hospitalized.

A U.S. study followed 12144 implant patients (mean age 31) and 3614 other plastics patients (mean age 40) from 1970-2002. 29 (0.24%) implant patients suicided vs. 4 (0.1%) other plastics patients. Thus, the 29 suicides were 1.6 times more than expected (SMR=1.6).

Interestingly, the risk of suicide was increased only after ten years; 22/29 died after 10 years. And while the majority killed themselves before 35 (16/29, SMR=1.4), the biggest risk was for >40 year olds. (SMR=3.4)

Really interestingly, the authors found that for breast implants there was no excess risk for any kinds of accidents-- why should there be, they were accidents-- except car accidents. Hmmm. 10 MVA deaths (occurring 15 years post implant) vs. 0 for other plastic surgery. The authors speculate these may not have been accidents.
Swedish study, prospective but no comparator group, of 3521 women (mean age 31) found 15 (0.4%) suicides, SMR 2.9.
Finnish study of 2166 breast implant women from 1970-2000 were studied (retrospectively) until 2001; there were 10 (0.4%) suicides, SMR 3. 6/10 happened in the first five years (in contrast to the U.S. study.) (Accidents here were 14, SMR 2.1. No explanation given for this.)
Canadian study: 24558 women with breast implants vs. 15893women with other plastic surgery from 1974-1989, studied through 1997. Mean age 32. Once again, overall all-cause mortality was lower for breast implant women, except in suicide: 58 (0.24% SMR 1.73) ) suicides vs. 33 (.20%, SMR 1.55) for other plastic surgery. Like the U.S. study, women over 40 with implants carried the greatest risk of suicide (SMR 2.3), but no relationship to how far after surgery suicides occurred.
So in these studies, appx. 0.4% of breast implant patients killed themselves, representing a threefold higher risk than the general population. In some studies, the risk of suicide was increased to 1.5 times for any type of plastic surgery. At least in North America, getting implants over 40 is a risk for suicide.   It goes without saying that the number of actual suicides was very small, and this could all be bunk.
All studies excluded implants for breast cancer surgery.
You may be interested in knowing that suicide is the only serious risk that has been regularly associated with breast implants-- silicone included-- and supported by real evidence, so far. Everything else is either no greater risk, or less risk. For example, there is a higher risk of lung cancer, but it most likely is related to smoking, not the implant.
The obvious next step is to see if there is a causative link between implants and suicide (likely impossible) or the implant is a clue to something else (poor self image, depression, drinking, etc.)

Something else: the stereotypical breast implant recipient (e.g. 20 year old coed in Playboy) is not really the typical recipient. The average recipient is older (mean age 34,); is more affluent; is married (75%) and has two kids; had kids at younger ages; has had abortions; and smokes. I mention this so that you have the right person in mind when you go looking for risks.
Other fun facts:
80% are cosmetic, 20% are breast cancer surgery reconstructions.
290,000+ breast implant surgeries done last year (compared to 130,000 in 1998). 25% are replacement surgeries for ruptures, pain, etc. Compare to 324k liposuction and 300k nose jobs.
10% of US women have implants. (This seems wrong.) 95% are white.
10% did it in California.

Since we're on the subject of implants and suicide, it seems to me an easy maneuver to fill breast implants with liquid explosives, puncture and mix. I am not sure why no one has tried this, actually-- or, more specifically, why no one at the TSA is looking for this as they stop to search my stupid tube of toothpaste.   Not that there's any good way of checking, of course.

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===== ====== ===== The Last Psychiatrist: British Medical Journal Sends Its Scienticians To The Internet

And finds that "Suicide searches produce disturbing, unsurprising results."

Damn the internet, damn it and its tubes.

I'm not sure if I should get angry or laugh. BMJ. Not Weekly Reader. BMJ.

An article in BMJ tries to determine how much information about suicide is online, and whether the sites are pro or anti suicide. They searched the internet, and found:

Altogether 240 different sites were identified.Just under a fifth of hits (90) were for dedicated suicide sites. Half of these were judged to be encouraging, promoting,or facilitating suicide; 43 contained personal or other accountsof suicide methods, providing information and discussing prosand cons but without direct encouragement; and two sites portrayedsuicide or self harm in fashionable terms...

Or, as the news articles about this study say:

But perhaps most disturbing was that the most frequent results were pro-suicide. "The three most frequently occurring sites were all pro-suicide," note the authors, who also found that "Wikipedia was the fourth most frequently occurring site." [emphasis mine.]

So I guess the internet is awash in suicidophilia. Or maybe BMJ doesn't know how to use Google?

The [search] terms used were: (a) suicide; (b) suicide methods; (c)suicide sure methods; (d) most effective methods of suicide;(e) methods of suicide; (f) ways to commit suicide; (g) howto commit suicide; (h) how to kill yourself; (i) easy suicidemethods; (j) best suicide methods; (k) pain-free suicide, and(l) quick suicide.

"Damn it! I typed in "naked porn stars" and all I got back was naked pornstars! What the hell is wrong with this thing?"

Try searching "suicide prevention." Ok, see? Can we all go back to worrying about illegal music downloads?

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===== ====== ===== The Last Psychiatrist: Can Narcissism Be Cured?
The wrong question.

A.

"Dear Alone: I read your descriptions of narcissism, and it sounds exactly like me. I'm terrified I'm a narcissist. It's just like you wrote: unlike other people, I can't seem to make meaningful connections with people, and when I try it indeed seems unreal, scripted. Other people seem to have legitimate emotions, be happy, or in love, or angry, or guilty, and to me it always seems like I'm-- just a little bit-- faking it."

Narcissism says: my situation is different. I am not like other people, who are merely automatons, shuffling towards oblivion.

B.

"Why are you so obsessed with narcissism?"

Describe the march of history over the past 100 years. Answer: Fascism, then Marxism, then Narcissism.

What distinguishes the three? Technology.

What followed fascism? War. What followed Marxism? War.

C.

"But I want to change, I want to get better."

Narcissism says: I, me. Never you, them.

No one ever asks me, ever, "I think I'm a narcissist, and I'm worried I'm hurting my family." No one ever asks me, "I think I'm too controlling, I'm trying to subtly manipulate my girlfriend not to notice other people's qualities." No one ever, ever, ever asks me, "I am often consumed by irrational rage, I am unable to feel guilt, only shame, and when I am caught, found out, exposed, I try to break down those around me so they feel worse than I do, so they are too miserable to look down on me."

If that was what they asked, I would tell them them change is within grasp. But.

D.

"So all is lost?"

Describe yourself: your traits, qualities, both good and bad.

Do not use the word "am."

Practice this.

I.

Instead of asking, "why do I feel disconnected?" ask the reverse question: "what would I feel if I wasn't disconnected?" Be specific, say the answer out loud.

Go ahead, take some time, think about it. What does connecting feel like? I'll wait.

Let me guess: you have no idea.

All you have for an answer is images, fleeting thoughts. Nothing concrete. Some words, some phrases, bits and pieces of conversations you may have heard or that you daydreamed.

Now ask yourself, where did you get these images and phrases?

Imagine two people: real, or from TV or movies, that are in love. Pick two people whose love you'd like to emulate. Imagine them kissing, looking into each other's eyes. Imagine them making love.

You wish you had a love like that, but you don't, and every time you try, to get it, it is failure. Here's the reason: are you imaging real people, or TV characters?

II.

The 1980s said: "TV is a bad influence, pushing our children down the wrong path." Of course, it's Newton's First Law: a body moves in the direction of the force unless it is opposed by another force.

Where will they learn about love?   They could learn from TV, or they could learn it from the generation adults with the highest divorce rates in history. They could learn about the difficulties of raising kids from an ABC/Disney Special, or from the generation with the lowest birth rates in history. They could learn about morality from Sesame Street, or... but Dad always remembered to send in his pledge to PBS.

Parents had no time for any of these lessons. So instead, to feel like parents, they worried that too much sex on TV would turn everyone into sluts. That didn't happen, I spent most of my twenties checking. What did happen, however, is that a generation of males started overtly, without shame, craving sluts, and a generation of women would often pretend to be sluts. Think about this: the act was that they were sluttier than they actually were, not more pure than they actually were.

Parents were right: TV could influence kids. But not in the expected way.

But wait-- could TV be so powerful? No, of course not. But how much force do you really need to push a child in a polyester snow suit across a frozen driveway?

People ask: "why do you focus on pop culture?" Because that's all the culture 300 million Americans ever received for 30+ years.

III.

Imprinting was famously depicted by Konrad Lorenz who had a gaggle of geese following him, behaving like him, in love with him. Less famously known: it took him only 48 hours to alter their identity.

And without the use of TV.

IV.

So now what? TV taught you how to love, it showed you what love looks like, feels like. But when you're actually in love, it doesn't look like that, so you secretly suspect you don't have the capacity for love, that there's something wrong with you.

Same goes for sadness. And it's worse when you're in the presence of someone else's sadness, you have no idea what to do. All you really know about experiencing these emotions is the script you got from TV. "Oh your husband died!? Oh my God, that's terrible! I'm so sorry for you!!" But you don't feel any of that. Nothing.

So you think to yourself, what the hell is wrong with me? This woman's husband died-- sure, I can fake it, but am I such an empty monster that I feel nothing?

Of course you feel nothing. Why would you?-- it's not your loss. What's wrong isn't your lack of feeling, but that you think you have to feel something, that you have to tell this woman, remind this woman, how horrible is her loss. You think the only way to connect with people is to have their emotions. You think she wants to connect with you. You think she wants your help.

The problem isn't your lack of feeling, it is that you think that unless you feel it's not real. You forget that she has a life that doesn't have you in it.

What you should say is, "I'm very sorry to hear that. Is there anything I can do?" and that's it. But that feels insufficient. You think this because you think that there is something you can do, that the sadness is not real for you so it must not be real for her and you thus have the power to change it.

She's not looking for you to be sad, she's not looking to you for anything, her loss is bigger than you. If she needs anything from you, it's sympathy, not empathy.

But no one taught you this. So you fall back on the character "man helping grieving widow." Action!

The problem isn't that you don't know how to connect; it's that when you do connect at all, you don't know what to do next. It's your unrealistic expectations of what connecting is supposed to be. TV is always about beginnings, not middles. Like love. The love you feel doesn't resemble the TV love because the TV love is the first three days of love, copied and pasted into a decade of episodes. But since you have no other reference point, after a real decade, you think, "I guess must not be in love anymore."

You are so unsure of your own identity that you don't know if you are supposed to be feeling, what you are supposed to be feeling, when you are supposed to be feeling. This is the same trouble actors have when rehearsing a character. They want to get it just perfect-- would Tom feel this? What's his motivation? And similarly you ask: would I-- the person I am pretending to be--   feel this?

V.

Narcissism is imitating by being. It is method acting all the time.

VI.

The problem wasn't TV, the problem was the absence of adults, real adults who took seriously their responsibility to the next generation, who lead not by words, but by behavior. Who, even if miserable or unfulfilled or unconnected had the decency to fake it for the next generation, for the people they touched. Who didn't cheat on their wives not just because they loved them, not just because it was ethically wrong, but because what kind of an example would that be to their daughters?

I know, everyone will disagree. Everyone, except daughters under 20.

VII.

I killed a mosquito yesterday, because it bit me and it hurt and I am not the Dali Lama.

The narcissist, however, says, "It's just a bug."

VIII. The Solution No One Will Like

"I feel like I am playing a part, that I'm in a role. It doesn't feel real."

Instead of trying to stop playing a role-- again, a move whose aim is your happiness-- try playing a different role whose aim is someone else's happiness. Why not play the part of the happy husband of three kids? Why not pretend to be devoted to your family to the exclusion of other things? Why not play the part of the man who isn't tempted to sleep with the woman at the airport bar?

"But that's dishonest, I'd be lying to myself." Your kids will not know to ask: so?

The narcissist demands absolutism in all things-- relative to himself.

IX.

"But I had really good parents!"

Sorry, Leonidas, you were simply outnumbered.

The best of parents can't beat the overwhelming influence of everyone else, of everyone else's parents, of TV, of journalism-- of a culture that says, "well of course! The old ideas were wrong, we know so much more now! We are touching up the last pages of history, from now on things are different..."

18 years of the best parenting still can't beat the morality lesson at the end of an 80s sitcom, presented as if it were a fundamental truth, known to all, incontrovertible.

So what about the next generation, those under 25?   If the problem was the unopposed influence of TV-- not the TV, per se, but the lack of opposing influence-- then the solution is some opposing influence.

I am nervous about recommending "the Classics" because it sounds contrived and pretentious, but anything that has withstood the test of time and is not something that was created to be consumed by current narcissist adults is as good a place to start as any.

Do the opposite of what the narcissists did. They wanted to know enough to fake it. They read just enough to use the book to build an identity, so they read about books, but not the actual books.

If nothing else, reading will keep you out of trouble: every moment reading those books is a moment not doing something your current adults created for themselves that you're stuck with by default.

X.

"Why do you waste your time with pop culture?" Because you may not be interested in pop culture, but pop culture is interested in you.

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===== ====== ===== The Last Psychiatrist: Can The Court Force Treatment on Jared Loughner?

my attorney has advised me to punch you

Jared Loughner shot Representative Gabrielle Giffords and 18 other people, which immediately suggested that he was a right wing nutjob, but, apparently, he was actually psychotic, which is ok because Webster's says those are synonyms.

He was found not competent to stand trial. This means his trial is postponed until his mental illness resolves enough for him to: understand the charges against him; participate meaningfully in his own defense; control his behavior in court; etc. See that last "etc?" That's the part that allows courts to do anything they want to you.

Loughner, however is refusing to take antipsychotic medication to get better. A more accurate restating of that sentence would be, "it is extremely likely that Loughner's attorney is refusing to allow him to be medicated, with the hope that trial is postponed forever, or at least until the attorney comes up with a really awesome defense, or people forget who Loughner is."

Let's Michael Foucault this whole discussion and recall that psychiatry is a medical specialty that is also used to set social policy.

Practically, this means that if the court wants to medicate Loughner against his will, they can. There is a legal process to follow, but it is simple and straightforward and completely not in any kind of dispute.

There should be no issue.

II.

So I was surprised to read that the American Psychiatric Association and the American Academy of Psychiatry and the Law, through Paul Appelbaum, filed an amicus curiae brief in support of forced medication. Why? Isn't this a non-issue?

In fact, there are two reasons you can forcibly medicate (only) prisoners. The first is Sell v. US: you can force antipsychotics for the purpose of restoring the defendant to competency to stand trial.

The second reason is Washington V. Harper, which allows forced medication of psychotic prisoners in the situation where they were dangerous to themselves or others.

So, again, I was confused. What's the debate?

The APA's brief had two purposes:

1. "When the courts address issues concerning psychiatric disorders, we want them to have accurate data on the nature and consequences of those illnesses and on appropriate treatments." The reason antipsychotics have traditionally been disallowed is because, as in Sell, there are significant irreversible side effects (tardive dyskinesia) that may outweigh the benefits. So the APA wants to update the court on the real risks, especially of the atypicals.

2. Sit down:

The second key issue the brief addressed was the importance of permitting authorities who have custody of a defendant to make decisions of forcible medication without having to go through a time-consuming judicial hearing on the matter.

The brief pretends that the issue is unscrupulous lawyers keeping their poor psychotic clients psychotic forever, to their great distress, just to avoid trial. Appelbaum would like Harper to be the standard; Sell is too bureaucratic.

In addition, we believe psychiatrists working in correctional facilities need the flexibility to deal with dangerous persons without the delay involved in lengthy court proceedings.
The APA assumes that treatment decisions should fall to psychiatrists, but it seems not to appreciate that these are psychiatrists in prisons who work for the government. There is massive, gargantuan pressure on psychiatrists to medicate and commit and diagnose inmates for all kinds of legal reasons. Harper may seem like the more psychiatrist-friendly standard, but it isn't. You want the standard to be Sell, because you want a way to avoid the pressure from the government.

The Loughner case is misleading because he is mentally ill and dangerous, but the APA wants to massage Harper to focus on the dangerousness. Here's a more typical example: the defendant is a violent rapist who has significant personality disorder but no clear psychosis ("no Axis I pathology.") He punched his lawyer. Now what? You commit him to the psychiatric ward because he's incompetent to stand trial and forcibly medicate him because he's dangerous. But he's not psychiatric! "Yes he is, it says it right there on the commitment papers: Psychosis NOS." So you ask how he got that diagnosis, and of course the answer is: we needed it to be able to forcibly medicate him.

I'm not going soft on rapists-- go ahead and sentence him to life. But don't send him to psychiatry because you don't know what else to do with him.

Doctors are given considerable deference to use their judgment; they are given greater latitude to violate a person's rights. The government will use the back door of the doctor's privilege to get what it wants. It is inevitable.

The issue is not whether psychiatrists should medicate people who are obviously psychotic and dangerous-- you don't need an APA amicus curiae brief for that. The issue is whether you want to force all prison psychiatrists to be responsible for the "treatment" of every violent person out there, simply because they are "dangerous."

The APA has always wanted the answer to be yes. And here, again, they do not understand the consequences of this. I can thus say, according to the strictest definition of the term, that the APA is completely insane.

Miscellany:

1. In the Harper case, the American Psychological Association filed an amicus curiae brief in support of Harper, i.e. that forcible medication without a hearing violated the due process and equal protection clauses. You are welcome to explore the disparity between the APAs.

2. Harper does not apply to civilians. You can force hospitalization on a guy for being dangerous and psychiatric, but you cannot force treatment on him without a court order. You can lock him down, but you cannot touch him.

If a psychotic diabetic patient whose sugar is life threateningly high is refusing insulin because aliens tell him to, upon psychiatric review you can force insulin on him, but you still can't force antipsychotics on him because the insulin is necessary to his survival and the antipsychotics are not.

We know that psychosis takes a few days to improve, even if the right dose/drug is hit on immediately. The fact that it takes days to work means you can't argue they are life saving, so you can't get past the need for a court order.

I will point out that even though what I've written is true, psychiatrists still routinely force medication on people, in jails and in hospitals. They're doing it for noble reasons, and I don't fault them, but it's important to know where the line is before you cross it. And, as importantly, it is far preferable that a doctor violate the law in order to do what's best for a patient, then it is for the government to sneak past people's civil rights by hiding inside their doctors' white coats.

--

Competency to be executed

Then I change my mind: Competency to be executed II

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===== ====== ===== The Last Psychiatrist: Catfish: The Real Danger Of Social Media

wild guess... is it a catfish?

Catfish is a movie about a guy who has a facebook relationship with a woman, and then goes to meet her and discovers... should I say "spoilers below?"
Spoil what? "The twist ending!" What twist? Darth Vader is Luke's father is a twist, Katherine Heigl is annoying is not a twist, it's a premise. Saying there is a twist ending is a vicious restructuring of the definitions of "twist" and "is."
"You'll never believe what happens..."   Yes you will. Exactly what you think happens, happens. The real mystery is why he never thought this would happen.
But you should see the movie anyway.

Cue trailer:

Not a twist: Uber-hott 19 yo Megan isn't really uber-hott, 19, or Megan. Huh. The only thing you don't know is if when he looks in that garage he sees Chthulu eating fetuses, or nothing. Twist: nothing.
But you're not watching this movie for the twist. This is, surprisingly, a movie you can watch a dozen times for reasons different than the critics noted.
Here's the plot: Nev gets drawn into on online relationship with a really hot 19 year old. Nine (9) months later begins to suspect something is not right, and so he drives the surviving members of REM up to her Michigan farm to get to the truth.

The truth is that "Megan" is really "Angela": a middle age, middle America homely housewife with a facebook account. What does it all mean?   Cue obligatory "on the internet, no one knows you're a dog."

II.

And:

But what's most interesting about Catfish isn't that the Internet allowed a smart filmmaker to be bamboozled for months by a make-believe Michigan family. It's that the Internet allowed him to figure it out, track them down and make a movie about it.

Funny, that's not what I thought was interesting. Maybe it was the subtitles, but the Korean bootleg I saw was about three megalomaniacs who actually believed it was completely ok to go a woman's house in the middle of the night, unannounced.

Don't be sucked in by the perspective, which in the movie is all theirs. Pretend you're the coroner: two people are reading the other's potentially unreliable online information, and one of them starts driving towards the other. Is that the version you saw in the theater? That's the real plot of the movie, and when you're able to see it like that you see that the true problem of online contact isn't what's posted online but who is reading. If a murderer posts a fake bikini facebook photo, and you show up at his house with suntan oil and a inflated expectations, you're the problem.

The problem of perspective is the true caution of the movie, missed by everyone. We value Nev's perspective more because he made the movie, but also because it features (not just uses) cameras, Google Maps, all of which are signals of neutrality, objectivity. If someone else made the movie about him and these events, you'd be aware of his insanity immediately. But by cleverly making the movie a POV, you're drawn into seeing things only his way.

Even the above Gawker critic couldn't not see it from Nev's perspective.   Of course the woman lied to him, but didn't he then turn and force himself into her real life only to make a movie? Isn't that worse? Make no mistake, this is a documentary of narcissism supported by the Apple catalog. If there was any movie that exemplified "a narcissist is one who sees himself as the main character in his own movie, and everyone else is merely supporting cast," it's Catfish. At one point he's frustrated by how his director-brother is pushing him to continue in the movie, and he says angrily but with no irony, "yeah, but this is about my life, okay?" Okay, wildman, settle down, we got it, it's your life, not hers.

III.

Here's the first clue you're in the presence of delusionality: at no point do any of these three ask the most basic and obvious question, why would this chick be interested in Nev? This isn't an insult, this is a legit query. Why would she want him? We understand why he would want her, but for the nine months of the movie, he has no sex with any other woman. "Well we can't all be as smooth as you." I sympathize, but you're missing the point: no one else who can see him wants him, but she does? That doesn't require some self-reflection?

"He charmed her." Slow down. "Megan" probably has had some experience being charmed, right?   At one point, she texts that she's baking a pie, "I'll save you a piece." Guess what he does with that. No, you'll never guess. Comedy gold. This guy delivers the obvious like he's writing for Daniel Tosh.

There is an absence of self-awareness coupled with an overflow of self-absorption. "Of course me!"

Put this in the reverse: at the end, when he discovers that he's been talking to a homely midwest mom, his friends explain that the mom is probably in love with him-- implying that of course a fat midwestern mom would fall for dashing New York sophisticate. That makes total sense. Even when they know that Megan must be an imposter, it never occurs to them that whoever the woman actually is might take one look at Nev and say, "hold on, you can't be the guy... is this a radio bit?"

The problem of this movie-- which perfectly encapsulates the most basic problem with America-- is that it doesn't occur to the audience either.   We've tricked ourselves into thinking that it's a completely expected that people will see us the way we want to be seen. And so any divergences from this must be quite obviously mean the other person is a jerk.

IV.

An example. Let's review some basic facts about Nev because he considers them important enough to put in his movie.   First, he wears a retainer. I know, I know, it's not cosmetic, it's for TMJ. Second, he spends an awful lot of time hanging out in his bed in nothing but his briefs, which only look like Spiderman Underoos because they are red. They're not Underoos. They're just red.

He loves the feel of a fluffy down comforter on his naked skin, that much is obvious.

See that pic, above, where he's sneaking up the dark driveway to peer into the garage of the mystery family that for all he knows could be cannibals?   He's barefoot. When he's thinking about the malleability of identity he likes to stick his hand down his pants. In fact, what he likes on his body even more than a down comforter is his hands-- he is constantly touching, rubbing, hugging his own body. I can say with complete certainty that this guy pees sitting down and still gets the seat wet. And you know how some guys think it's sexy when a girl has a tattoo of a sun or wings on their tailbone? Well, Nev likes them so much he has one on his tailbone.   I'm sure there's a funny story behind that, but I can assure you it's irrelevant.

So? So my reaction to all this was that Nev was utterly, genuinely, hateable, somewhere on the level of a Snookie or a David Hasselhoff or the Asian chick on Grey's Anatomy. He smiles like a Scientologist, he's monumentally passive aggressive-- I hated this guy. Hold on-- I realize that my own natural self-loathing hovers around an unhealthy 105%, hence the rum, but the point is that Nev-- as portrayed in this movie-- would never imagine that he generates this reaction in anyone. He probably can imagine people not liking the movie, but why would anyone hate him? It's inconceivable!

V.

One final example. Angela lives with two severely retarded children. They are stepsons; this is the life she chose. Through tears, she tells Nev that when she got married, she knew she'd be making some sacrifices, but she didn't realize that in fact she'd be "resigning from her own life."

So, she's telling him this because she wants some affirmation, not because she wants him to fix it. How could he? But Nev doesn't hesitate to repeat all of this to the husband during his interview. "You know, Angela told me that she feels like she gave up a lot..." There are two possibilities. One is that Nev thought he was so much more intelligent and empathic and nuanced than this stupid hick-- never mind that he's been able to support a very pretty and well maintained home, and everyone in there seems happy, keeps all their needs and a decade long marriage intact-- that aside, Douchekata figures he can Dr. Phil a decade long wound in their marriage with nine seconds of HD footage. The second possibility is that he didn't even want to do that, he just wanted to split the wound open because he needed the shot. I'm not sure which is worse, but I hated him just in case it was both.

VI.

Go another way: so Angela lied to them about her identity. So what? Who says they were entitled to the truth?

When they arrive at Megan/Angela's house and meet everyone they are on edge, what's going on here, none of this seems like Facebook? The family, especially the husband, is very friendly and cordial, but it could have gone the other way:   what kind of nuts are these? He traveled all this way to meet a girl? That makes it normal? "We want answers." You better keep your hands where I can see them. And why does Nev expect others to assume he is trustworthy? Because of what he wrote about himself on facebook? Haven't we established that that stuff is unreliable?

Well, let's look at his facebook, then: he's cut out a picture of her, naked, and put it onto a picture of himself, naked. You know who does that? People who narrate their reality.

"It rubs the lotion on its skin or it gets the hose." This photo creeps me out so much I had to stop drinking. Yeah. On the drive to her house, shouldn't he have to call the Michigan police and register, or something?

It cannot occur to them that what they are doing is wrong because it isn't wrong-- there are no Right and Wrongs, there are only his right and wrongs. They have a need to know, they want to meet her, so it's all ok. The movie trailer plays like a horror movie, yet they don't feel any fear at all, which is weird, right? You know Megan isn't Megan and you know you're wearing red underwear, shouldn't you bring backup or something?   As bad, neither do they worry that someone might be scared of three strange men in the dark. Look up at that picture. Why should anyone trust them? If you come at me and say, "hey, are you the guy who writes The Last Psychiatrist?" then you better come at me strong because I will take you down.

The critics will deftly signal without spoiling that this isn't really a horror movie.    Let me correct that right now: it is absolutely a horror movie. Fortunately for Angela, the psychopaths just happen to be pussies.

VII.

There is a line, and that line is online. The agreement we've all accepted, it is there in your ISP contract, is that we are willing to trade exhibitionism/voyeurism for greater respect in real life. Or, less privacy online for more privacy offline. The girl on facebook "agrees" to use a bikini profile pic because you agree not to stalk her, in fact, you agree not to mention it to her in person at all. That's the deal. If you say, "hey, I saw your pics on facebook and I wanted to meet you," she is allowed/encouraged to go Desert Shield on you. That's the deal.

This is why huge corporations can't fire people based on what they did online. "Well, we don't want that kind of person working here." They're all that kind of person, you're that kind of person, every one of us carries around multiple shames that would exclude us from society, let alone Walmart. It is information bias, just because you know she is a slut or he is a racist doesn't mean that everyone else isn't. Why does so much of us have to be in the job? Jobs suck, we do them in spite of ourselves. Asking me to clean up my online profile because you want to pay me $11/hr is a bit much. Shut it.

It's the same deal that goes with sexy clothing. The contract is, you show a lot of cleavage, we don't stare. That's the deal, not the reverse, not the "well she put it out there so I can stare." None of this is conscious, explicit, it's SOCIETY. When we start staring too much, they'll start covering up/getting private security. And society changes. It's a symbiosis that is always in flux, and this is where it stands 2010. Like it or not.

"Well, sometimes they want you to stare at their breasts. How can you be sure it's not you they want? Easiest question in the world: if you're not sure, it's not you. She'll let you look obliquely because she doesn't have control over the velocity of light, but if you stare too long expect a manicured finger in your eye. That's the deal.

Nev breaks the deal. You can't fault him for googling and investigating, but he's not permitted to go to her house. That's the deal.

At the end of the movie, he reveals that Megan is actually Aimee Gonzales.

Note that he did all this because he thought she was real. Now that everyone in America knows she's real...

To be clear: I don't fault Nev et al for making a good movie about himself, I deeply fault all the critics (and audience members) for celebrating the wrong message. Only-- and I can't believe I'm about to say this-- a male dominated, female-as-commodity narcissistic perspective would think that the moral of the movie is that a man might get fooled. The real moral is that some men will drive 300 miles just on the chance that you are hot. Imagine how far they'll go to kill you.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: CATIE Reloaded

And enough with the notion that medication compliance is a good proxy for overall efficacy.

All of these horrible psychiatry studies-- CATIE, Lamictal and Depakote maintenance trials, etc-- keep telling us how long patients stay on medications, because they say this means the drugs are working. The authors think that if a drug is working, they patient will stay on it. But you would think this only if you didn't actually treat many patients. I can make a similar argument that staying on a medication is inversely related to efficacy-- because when a patient feels better, they simply stop taking their meds.

Think about antibiotics. People don't finish the full 14 day course, precisely because they feel well. If they felt sick, they would probably take them longer than 14 days. In fact, people overuse these antibiotics even when its a virus, despite the antibiotic having no efficacy at all.    They will demand an antibiotic even though know that it shouldn't be doing anything.

Same with pain meds. Oh, that's an acute problem? How about the chronic problems of diabetes and hypertension. People will skip/miss/forget doses when they feel asymptomatic, and will be more compliant when they have symptoms associated with these illnesses (e.g. headache, dizziness, etc.)

Look, I'm not telling you that compliance and efficacy aren't related. I am saying that if you want to measure efficacy, don't use compliance as a proxy-- go measure actual efficacy.   And don't tell me it's too hard. You got $67 million for this study. Find a way.

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===== ====== ===== The Last Psychiatrist: CATIE: Sigh

1. You know, if you're going to be rigorous about BID dosing schedules because the FDA requires it, why so liberal with total dosing for Zyprexa? A mean dose of Zyprexa is 20.8 is way (150%) above FDA guidelines. For comparison, that would have meant dosing Geodon at 240mg, Seroquel at 1000mg, and Risperdal at 6mg. BTW: a mean of 20.8mg means that a lot of people were dosed with MORE than 20.8mg (max=30mg).
2. The miracle here isn't that Zyprexa won, but that Zyprexa 20mg barely won against Geodon 114mg.
3. Why Trilafon (perphenazine)? Originally you thought all conventionals were the same; so why not Haldol? Or Mellaril? You say it's because it had lower rates of EPS and TD, which is fine, but then why exclude TD patients from that arm?

4. So you excluded patients with tardive dyskinesia from the perphenazine group (fine) but then had the nerve to say people tolerated it as well as other meds? Do you think maybe people who have TD may have different tolerances to meds? Different EPS? Different max doses? That they're just different?

5. You can't generalize from an obviously slanted "typical" arm to all other typicals. If you chose Trilafon over Haldol because of better tolerability a priori, you can't now say that "typicals" have equal tolerability to atypicals. Why not pick two typicals of differing potencies (like Mellaril and Haldol) and infer from there?

6. Do you actually believe-- does anyone believe-- that any of these patients are compliant with BID regimens? Especially with sedating meds like Seroquel?

The secret to understanding CATIE 2 is to understand that there are two CATIE 2s.

CATIE2-Efficacy: People who dropped out of CATIE 1 because their med didn't work were randomized to Clozail, Zyprexa, Risperdal or Seroquel. On average, new Clozaril switches stayed on 10 months, everyone else only 3. 44% of Clozaril stayed on for the whole 18 month study; only 18% of the others completed the study.

CATIE2-Tolerability: People who dropped out of CATIE 1 because of side effects (not efficacy) were randomized to Zyprexza, Risperdal, Seroquel, and Geodon (not Clozaril.) Risperdal patients stayed on for 7 months, Zyprexa for 6, Seroquel for 4 and Geodon for 3.

CATIE2-Efficacy is fair. If you fail a drug, you're likely to do better on Clozaril than anything else.

CATIE2-Tolerabilty makes no sense at all. The reason Geodon was used is because it has "very different" side effects. Hmm. How? "In particular, ziprasidone [Geodon] was known not to cause weight gain." But this assumes that the intolerability of the first antipsychotic was its weight gain.

Most importantly is this: if a patient couldn't tolerate their first antipsychotic, how likely is it that it was effective? In other words, if it wasn't tolerable, it wasn't efficacious-- these patients could have been in CATIE2-Effectiveness study. So how did they choose?

Easy: they gave the patient the choice: Geodon or Clozaril? Out of 1052, half left altogether. 99 went into the Clozaril study (CATIE2-Effectiveness) and 444 went into Geodon (CATIE2-Tolerability.) Of the 444 in the Tolerability trial, 41% were actually labeled first drug non-responders. 38% were labeled as not tolerating their first drug, but of those, who knows how many were also nonresponders?

And 74% dropped out again.

If you take the 444 in the Tolerability study and divide them into two groups:

those who left CATIE1 because of lack of efficacy: then switching to Zyprexa or Risperdal kept them on their meds longer. (Which makes no sense again: this is the same thing as the CATIE2-Effectiveness, where (except for Clozaril) there was no difference between Seroquel, Zyprexa and Risperdal.)
those who left CATIE 1 because of lack of tolerability, then it made no difference what you switched to.
Sigh.

And what's with the blinding? In every other study with a clozapine arm, you equalize the weekly blood draws by making everyone have to submit to them. But in this case, they unblinded clozapine so as not to have to subject all these people to blood sticks. Except they were subjecting them already-- they were checking blood levels.

And where was perphenazine? "[CATIE1] did not anticipate this unexpected result [that perphenazine would be as efficacious] that challenged the widely accepted (but never proven) belief that the newer atypical antipsychotic medications are better than all older antipsychotic medications" and so was not considered for CATIE2. Apart from the fact that it is simply untrue that anyone thought the atypicals were more efficacious than the typicals, it is furthermore untrue that that the authors did not "anticipate this unexpected result." In 2003, after basically doing Medline meta-analysis, they found that "not all of them were substantially different from conventionals such as perphenazine."

What's funny about these guys is how they conveniently lump all typicals together but arguing for differential effects of individual atypicals; then argue typicals are different from each other to justify picking Trilafon; and then say atypicals are different from each other ("not all of them were different") but typicals are all pretty much the same ("conventionals such as perphenazine.")

Bottom line:

The stated purpose of CATIE2 was to help clinicians decide which drug to switch to if patients a) failed their first drug; b) couldn't tolerate their first drug.
The divorce rate in America is 40-50%. Say you get divorced, and a friend says, I have two women for you, Jane and Mary. If the problem with your first wife was that she didn't turn you on, you should marry Jane. If the problem with your ex was that she was annoying, you should marry Mary.

What's going to happen here is that your second marriage, to either girl, is doomed. Certainly more than the national average of 50%.    How long is it going to take before your second wife doesn't turn you on either? How long before you find stuff intolerable about her?    The answer is, more likely than your first marriage-- say, 75%-- because the problem isn't your wives, it's you. You've framed the question in an idiotic and arbitrary manner. You don't get married to get turned on OR to be with someone who isn't annoying. You want the marriage to have both simultaneously, and much more. These things are not separable. This is CATIE2. A meaningless dichotomy-- efficacy and tolerability are not separate, let alone opposites-- used to create a false paradigm of medication selection.

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===== ====== ===== The Last Psychiatrist: Celebrities and Narcissism
If, as I say, a narcissist is one who thinks of himself as the main character in a movie, then what about those who actually are the main characters in a movie?

An article written by Young and Pinsky-- yes, Dr. Drew Pinsky, the host of Loveline and now Celebrity Rehab.

200 celebrities, as defined as famous people who appeared on Loveline, were given the Narcissistic Personality Inventory and compared to 200 MBA students.

Guess what? Celebrities scored higher than MBA students. Big surprise.

But some interesting findings:

Female celebrities scored higher on every component than males, but especially high on exhibitionism, superiority, and vanity. (The other components are exploitativeness, authority, entitlement and self-sufficiency.)

Breaking the celebrities down according to "profession":

Reality TV stars had the highest scores, (most significantly in exploitativeness) followed by comedians and actors (close 3rd), then musicians.

The MBAs showed the opposite distribution: males were more narcissistic than females, especially entitlement and self-sufficiency.

For example, #10 "I can talk my way out of anything" is most heavily loaded for "exploitativeness" but negatively weighted for "exhibitionism."

Reminds me of a joke by Janeane Garafalo (from memory): you know, all actors in LA are the same, they're just waiting for your lips to stop moving so they can talk about themselves.... I guess it would help if I were paying attention, but they're just talking crap...

===== ====== ===== The Last Psychiatrist: Charles Manson's Single Moment Of Clarity

Too late.

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===== ====== ===== The Last Psychiatrist: Charlie Sheen Has An Awesome Experience, This Time With Drugs and A Hooker, Which Was The Same As Last Time

next

Charlie Sheen:

Sheen appeared highly intoxicated when officers arrived to his room around 1:30 a.m., and a woman with him said they had been out drinking and partying that night, according to a law enforcement official. She said he was yelling and tossing furniture when they returned to the room

The part not in this paragraph is that he was naked, she was naked, she was a prostitute, and she was hiding in the closet. Cocaine was probably involved. Also, he had just spent the day with his ex-wife and their kids, all who were asleep in the next room. That's class.

First, the drugs. I know this isn't a particularly psychiatric thing for me to say, but I like dropping truth bombs on the unsuspecting: lots of people get drunk and high and... do nothing. Watch Craig Ferguson. Play Xbox. Take a nap. Go to work.

I'm not condoning it, but our minds get tripped up at the drugs as if therein lies the majority of the explanation, and I'm sure Charlie et al would like us to stop there as well.

This goes for psychiatric illness, should he have one. "He's bipolar." So? Seriously, what am I supposed to do with that? Society can't have it both ways, you can't tell me "it's a hurtful stereotype that the mentally ill are violent" and then 180 it and say "he got violent because he was mentally ill." Sometimes they go together, sometimes they don't, but you can't offer either one as an "everybody knows that" and hide behind your postmodernism.

Second, he has no incentive to stop. There's a physical toll on his body, I guess, but meanwhile he's having drunken sex with super hot women-- so what if they're prostitutes--partying, going to clubs, etc. He trashed the Plaza Hotel. That's where he's at with his addiction, the Plaza Hotel. He's three moongates away from anything resembling rock bottom.

When he gets caught, he gets a slap on the wrist and his show gets picked up for another season. The picture they splash all over the news that reflects his insanity is this one:

I'm not advocating punishing him, but you can see that the whole system is set up to keep him going at this level. Surprise. He does. If you're wondering why this nut doesn't change his life, it's because you pay him not to.

II.

"He's not a bad guy, he just has a problem." Actually, you have that backwards, he doesn't have a problem, he is a bad guy. I know this because he beat up (allegedly, at least) two women. This isn't the place to get into whether the bitch done deserved it, running her mouth all damn night long, the point is his thinking about it. If I (allegedly) beat up a girlfriend, I'd feel TREMENDOUS guilt, I would really have to rethink the need for my existence. I'd also be scared that she'd call the cops and shamed as a woman beater, ruining my life and/or career; and I'd be Ed Norton 25th Hour terrified of going to jail. Charlie Sheen apparently feels none of these fears, at all, ever. After he beat up the first bitch who deserved it he should have sworn of bitches just out of self-preservation, but no, back into the mix, and if the next one gets out of line she'll be getting the People's Elbow.

That's narcissism-- "writ large" as they say in magazines that suck. Even if the drugs made him completely insane, the fact is that he regularly puts himself in situations that involve something getting punched, and the only explanation for that is that he doesn't see rules as objectively applying to him, he only sees his behavior as situational, in his context. In other words, there's always this: "well, hold on, this is a different situation, let me explain..." followed by two hours of words. There's always an explanation, it's always different this time, which just means it's exactly the same.

III.

"It's an addiction, he can't stop." Put the microphone down, wildman. Everyone can stop. You may be bad at math but your brain is doing math all the time and it calculates to the millivolt whether the reward is worth it.   Internal forces conspire against you, for sure-- maybe it values things wrongly and maybe your body tries to to trick you when you want to quit by making you more hungry so you eat more, or more anxious so you drink more, more bored, more angry, maybe you remember more vivdly that your wife cheated that one time, or that Karen is dead-- whatever-- but it still ends up being a binary question, "do I do it or not?" You can argue that the scales are loaded one way or another but it is a scale nonetheless. The secret of the universe is this: all decisions are binary. You will never be happy if you fight this.

IV.

I can help you with your choice, with varying success, but when you are punching other people and that isn't enough to get you to stop no one can help you. Before you say, "I want to stop drinking" you have to first have thought it more important to say, out loud, "I want to stop punching people." The latter is for the good of others; the former is for yourself, with the byproduct of being good for others. That's why it fails.

V.

Denise Richards got him to the hospital, and is now trying to protect her kids from Charlie's nonsense and media exposure. You know how I know that? She was on TV blabbing about it. I certainly don't fault her, but the desire to interpret personal events in a public forum changes the meaning of the events. "My fans are going to want to know." Sure they want to, but that doesn't mean you should tell them. In fact, for your own good as well as theirs, you shouldn't.

The result is it goes from being outstandingly negative to almost positive. If you hired a prostitute or punched a girlfriend you'd hardly put it on your Facebook, but this gets written up in TMZ as Sheen The Party Wildman. Cool. The male deconstruction of it is, "man, if that was me, I wouldn't be trashing the hotel room..." That's where he went wrong, see? He took it too far, but the lifestyle sounds enviable... and anyway he sounds like he'd be fun to hang out with, right? Ladies? Am I right?

I'm in

If the repercussions for nonsense and punching your girlfriend is another girlfriend and more nonsense, it's hard to identify a reason to stop. Which is why it won't. But you're being lied to, by yourself. And now I'm not talking about Charlie Sheen, I'm talking about you.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Check Out My New Acura-- ads?

this is not an Acura ad

I.

I send my partner a note: "Check out my new Acura ads!"

Acura is having a 24 hour promotion to coincide with the release of its new car, hence the ads you see today on my site. The ads mean money, of course, but I sent the note with some pride.

The ads signify a form of success, that my blog is Acura-worthy for advertising. Never mind if that's true-- that word "signify" indicates something else going on: I'm judging the quality of the site by the ads on it.

I've never judged a person by their actual car, because I'm hyperconscious of product branding and message, I am always alert to the deception. But here I am using the ad itself as a signifier.

Subtle flash animations, good photography or design, and of course the product in the ad-- all these things are signals to me about the site that has them. Of course, the ads mean different things to different people-- Acura ads may symbolize a sell out, or out of touch-- but the point is that the ads themselves, not the car, symbolize something. And what it symbolizes is: this company endorses you.

Many sites like mine have google ads, which only "pay" if you click on them; hence, they pay very poorly. But they're easy to install, so most sites have them. Consequently, it's as much the ubiquity of Google ads that signifies "amateur" as the absence of the more branded display ads (e.g. Acura.)

People often comment about what Google ads I have on my site, but I have no control over them, whether it's advertising a camera or ginseng extract is up to them, not me. Frankly, I think Google uses it to punish bloggers. I wrote an only minimally critical piece about Google in 2007, and ever since then they've been serving Dianetics ads and destroying my email with the Android.

But not that I am aware how I (previously unconsciously) made a judgment about websites based on the kind of ads it serves, the scientific question becomes: does the ad change the traffic?

So I looked.

II.

It's only a few hours into the Acura ad campaign, but I can tell you the trend: it hasn't increased the number of hits to the site, but it has changed the click through rate. About 10% more people by this time have clicked through to read posts (in other words, fewer people landed on the homepage and left without clicking on a post.) I am amazed at this result, but there it is. The presence of an ad for Acura enticed people to stay awhile.

Bigger websites out there should take note. If you run a stock advice site, make sure your ads are from the big brokerage houses and banks, simply because it looks like they endorsed you. And if you really want to look like a professional, dump the Etrade ads and get WSJ or Goldman Sachs to advertise with you.

But if it turns out to be true that the type of ad alters reader behavior, then the next question to ask is: what would happen if you placed a fake Acura ad on your site? Copied one from some other site and slapped it up there?

People already do this to themselves: luxury car logos as necklaces (old school, I know); college stickers on the rear windshield. This isn't the same as having the product around to brand you; nor is it the same as the product itself prominently displaying the logo (e.g. Juicy on the butt). This is a conscious decision on a person's part to take the brand (not the product) and use it to endorse themselves.

Could you command a higher subscription rate if your ads were better? Could you get better advertisers because they see an Acura ad is already there? Could you manipulate the market by using fake ads?

I'm not sure this has ever been studied, but the ramifications are huge: for one thing, it would mean the end of display advertising. Why would they pay you, when you maybe should be paying them?

----

http://twitter.com/thelastpsych

---

For those with ad block-- do me a solid and turn it off when you visit this site. It's better than a subscription...

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===== ====== ===== The Last Psychiatrist: Chicago Tea Party

It makes a lot of Americans insane that Wall Street execs are paying themselves gazillions in bonuses, even as they demolish their own firms and the financial system. They blame Wall Street for the financial crisis.

Then there are others who have a different explanation.

Rick Santelli, former bond trader and now CNBC reporter. The highlight is 0:59-1:20.

(Link to video here)

It's worth hearing for yourself, but here's the punchline: "ask anyone here if they want to pay for the mortgage of their neighbor with the extra bath, who can't afford the house."

Let's leave aside whether he is right or wrong. I sympathize with his perspective, though it's evident he thinks America is stronger than I think it is, he thinks it could recover without any government aid, he thinks people will just buckle down and ride it out like they did the last Depression. I disagree, I think they get guns.

Let's leave that aside. What you need to observe is that his sentiment, shared by millions and millions of people, has the same fervor and anger as the "put the Wall Street bastards in jail" camp. You just don't hear about it very much.

Note also that he isn't angry at the government only, he's angry at other Americans. While there are millions of people who think their government and capitalism have failed them, he's speaking for the millions who think those people are the problem.

These are personal attacks about American against American, this is a new level of divisiveness.

Santelli knows enough about the stimulus package to criticize it on its merits, but what infuriates him is its symbolic meaning, a la Atlas Shrugged, that he's responsible to pay for his fellow Americans simply because he has the money.

On the other side, today you have South Carolina Representative James Clyburn saying that opposition to the stimulus package is a "slap in the face of African-Americans." What he doesn't realize is that saying it that way doesn't make people support the stimulus, it makes people resent African-Americans.

Maybe the best thing Obama could do is move as far to the left as possible. He will never be centrist enough, and certainly not rightward enough, to satisfy the Right. And he'll meanwhile infuriate the Obamaniacs who won't be able to recall if they were voting for Hope or Change.

Who knows.

But a prudent person will be less concerned with picking a side, and more concerned that sides are being picked.

Class warfare is back in earnest.

He calls for a Chicago Tea Party (he and the CBOE are in Chicago.) Before you jump with him or on him, a history lesson: the Boston Tea Party wasn't a protest about the British raising taxes on tea; they were protesting the reduction of the tax on tea, which meant the East India Company tea was even cheaper than the smuggled tea provided by wealthy colonists.

The British were using a low tax to seduce the colonists. Would colonists accept British rule-- the right to set taxes-- if it got them cheaper tea? Samuel Adams hadn't read the Grand Inquisitor but he heard about it. They dumped the tea before anyone had a chance to say the words that destroy civilizations: please take away our freedom, it's a small price to pay.

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===== ====== ===== The Last Psychiatrist: Child Rapist-Murderer John Couey Loses By Eight

Here's an example of what I've been talking about.
I'll spare you the details, but John Couey is found guilty of kidnapping, raping, then burying alive, 9 year old Jessica Lunsford. Here's the part relevant to our disussion: defense attoneys said Couey could not be executed because he was mentally retarded-- his IQ was tested by the defense at 64. (They even let him color with crayons during trial.)
But, and I'm quoting:
Circuit Judge Ric Howard in Citrus County ruled that the most credible intelligence exam rated Couey's IQ at 78, slightly above the 70 level generally considered retarded.
That's it, people. 8 points.   We may not agree whether the death penalty is good or bad, but can we at least agree that decisions of life or death shouldn't come down to, well, how stupid you are?

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===== ====== ===== The Last Psychiatrist: Children With ADHD Drugs Score Higher on Tests

CHICAGO - Children on medicine for attention deficit disorder scored higher on academic tests than their unmedicated peers in the first large, long-term study suggesting this kind of benefit from the widely used drugs.

Wow. WOW. I get more actionable information from porn.

1. The comparison isn't between kids getting meds and "unmedicated peers" but kids with ADHD who get meds, and kids with ADHD who don't get meds.

1b. "Both groups had lower scores on average than a separate group of children without ADHD."

2. The study indicates that the kids derived a benefit on test scores equivalent to 1/5 of an academic year, by 5th grade. That would be two months. (Still below non ADHD kids, though.)

2b. In order to derive this benefit, kids needed to be on the medications for about 3 years consecutively; in other words, they had to "learn" while on meds. Risk-reward?

3.
Our objective was to determine if reportedmedication use for attention-deficit/hyperactivity disorderis positively associated with academic achievement during elementaryschool. CONCLUSIONS. The finding of a positive association between medicationuse...and test scores isimportant, given the high prevalence of attention-deficit/hyperactivitydisorder and its association with low academic achievement.

You say, "the study did find that stimulants were effective. Wasn't that the whole point?"

II.

So that's the kind of study analysis they talk about in medical school but don't bother to teach. See how awesome it is to look critically at the methodology of a study, differentiate clinical significance from statistical significance?    (Never mind that the study produced nothing new.)

This kind of analysis is the intellectual equivalent of turning a gun sideways. Looks cool to anyone who's never actually held a gun, but dangerously unreliable when it matters most.

The question: what do the authors want to be true?

III.

First of all, was this study really necessary, let alone important enough to end up in Pediatrics?

There are already plenty of studies examining, specifically, stimulants and school performance. Here are seven: 1, 2, 3, 4, 5, 6, 7.

I'll admit that this study is unique in that it is prospective and long, but do we need a unique, prospective and long study of what we already know?   It isn't even important research in that it has been pretty much established that there aren't significant effects on academic performance overall in ADHD kids. So why bother doing this study?

Or, you might ask me: "why does this study, in particular, bother you?"

The author names aren't important here, it's their degrees that are important. 6 authors-- only one an MD. The rest are PhDs.

Do you think PhDs care about ADHD drugs?    The study isn't about the efficacy of medications; it's about the validity of ADHD. "See? We're studying a medical problem. Can we get some grant money now?"

Don't send me back to my pirate ship yet. The authors are from the Petris Center, which receives funding to examine healthcare policy. They got $900,000 from NIMH to study this. Was it worth it?   But if there's a million dollars out there to study something that could have been done with a review paper (or a blog post), then you're going to do it.

This is the basic problem with academic research. Covering the same old ground, over and over, focusing on whatever is institutionally (or politically) popular.

Given this kind of research, I have no expectation that any progress will be made in the "treatment of ADHD," let alone in improving anyone's academic performance.   I am entirely confident, however, that this lack of progress will cost millions and millions of dollars.

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===== ====== ===== The Last Psychiatrist: China Needs Fewer TVs, Or A Billion Of Them

I'm just as surprised as you, but at least I'm drunk

I.

Reread Part 1. What's happened since?

II.

Studies have apparently shown that soap operas shown in developing countries introduce/reinforce progressive values like female empowerment, education, equality, with very real effects on the society (e.g. birth rates are lower, girls stay in school longer, etc.)

From a news article entitled, "How soap operas could save the world":

"The evidence we have from these academic studies is that quite often [soap opera viewers in developing countries] take away different attitudes toward things like how many children they want, what is acceptable behavior for a husband toward his wife, what is the breakdown in a household of responsibilities over things like finances, should we be sending girls to school," says Charles Kenny, an economist at the World Bank.

Soaps are particularly powerful because they attract so many devoted viewers. But other shows have similar effects.   Charles Kenny wrote more extensively about this in Foreign Policy:

When a woman reached the final five [of Afghan Idol] this year, the director suggested "it would do more for women's rights than all the millions of dollars we have spent on public service announcements for women's rights on TV."
Ok. But what did it change in women, exactly?

III.

1. How fast does the culture change due to TV? Probably only by a half-generation. Tick tock.

2a. If this effect is real, is it conscious and deliberate on the part of TV execs? Are interested parties creating shows to influence the culture (as opposed to simply selling product?)

2b. If this effect is real, why don't special interests (the government, the Christian Coalition, GLAAD, whatever) just give money to established Hollywood producers and say, "can you make cannibalism ok?" or "Please rewrite history or me." Works for Spielberg. So?

Certainly everyone loves to complain that TV is destroying society, why not get together and use TV to push the agenda you want?

Maybe they don't themselves know how real this effect is? Or maybe they don't want to. Maybe Spielberg doesn't want to change the world, just be thought of as the guy who wanted to.

IV.

You'll observe that the article's title isn't "How soap operas alter the world" it's "How soap operas could save the world"-- so it's a good thing, then? I know the result here was that women wanted empowerment, but it could just as easily have gone the other way. Why would a soap promote only the positive values of empowerment but not promote the negatively sexy ones such as showering with your boss and recording it?

This is from the Museum of Broadcast Communications article on soaps, specifically 1960s medical soaps:

The therapeutic orientation of medical soaps also provided an excellent rationale for introducing a host of contemporary, sometimes controversial social issues
Yay progress.   But here's the sentence immediately preceding it:

Their popularity also spawned the sub-genre of the medical soap, in which the hospital replaces the home as the locus of action... the biological family is replaced or paralleled by the professional family as the structuring basis for the show's community of characters.

Not to mention our own personal community of characters. Eventually even those get replaced with TV families.   Why else would there be an all new episode of Brothers and Sisters this Mother's Day?

V.

If you're still trying to figure out whether the studies show that TV violence causes real violence or TV progressivism causes real progressivism, you're approaching the question the wrong way. Those are accidental outcomes influenced not by the content of the shows, but the way TV makes you look at things.

And that way of looking a things is-- get ready-- narcissism. TV makes you look at things not starting from the thing, but starting from yourself.   No third world village woman looks at a soap and thinks, "I wish women had the right to freely choose their own husbands." They look at it and say, "I wish I could choose my husband freely."   It looks like a positive value, but that part's an accident. If you look closely, TV has only made her ask what she would like for herself. It promotes of the right to self-identify. You can argue whether that's good or bad, but the argument has to be about that.

VI.

Soap operas were stylistically different from other shows because they were open ended, unlike the neatly wrapped episodic dramas and sitcoms. They are also shot in quasi-real time. If a character says something dramatic and the show cuts away to another scene/subplot, when they return they will pick up exactly at the moment of the character's last words.   You are hand-held through every step of the emotional processing. It's impossible to apply the full force your prejudices to a social problem, e.g. abortion, when the show never gives you a moment to do so. You are carried through the entirety of the process through the character's life.

Soaps are also directed as a theater (opera) production, conscious of the audience's placement relative to the stage. Characters never turn their back on the camera; they'll turn their back on the other character (e.g. both facing outwards, towards the audience) and argue in a way no one ever does.

It's a stage effect: it pulls the viewer into their lives. You're in there, day after day, part of the action, part of the drama-- which they guide you through. No closed ended show can be as powerful.

It's hard to appreciate how unusual that was, because nowadays most TV dramas are run like soap operas: Sex & The City, Grey's Anatomy, Brothers and Sisters etc. That's what makes these shows so much more culturally influential than porn. Or church. If I was going to L. Ron Hubbard a religion, I would take Sunday services, and serialize them. Tune in next week.

VII.

TV doesn't just influence those who watch it, it's enough simply to be aware of TV:

Barely five percent of the TVs that are on at that time are tuned to Gossip Girl; in other words, very few people watch it. Yet there isn't anyone who doesn't know about it, even if it's imagined based on magazine covers or ads. So the existence of a menage a trois episode mainstreams it for people who don't watch the show, and that's actually more powerful a cultural influence. i.e. If you're a fan of the show, the threesome is specific: those three people are doing it. For everyone else not watching, it becomes background noise: "oh, people are having threesomes nowadays..."

This is why it is true that even if you are not interested in pop culture, pop culture is interested in you.

VIII.

Let's say I forbid my daughter or son to ever watch TV. What happens? Is she at a disadvantage because she is slightly less familiar with the rhythm of her social group? Will he be mystified by the seemingly contradictory desires in his female classmates? Will they both be frustrated and anxious at how everyone interprets social and political events using the exact same phrases, none of which they know?

IX.

Those of you expecting the rise of the Chinese Dragon and the collapse of the American Eagle are all going to die, along with your grandkids, way before that ever happens. Plan accordingly.

When Charles Kenny says TV is promoting values, what he means is western values. Right?   As long as America controls the horizontal and the vertical, western values-- or whatever CBS decides those are-- will be exported and fetishized. Accompanying those will be a interpretive framework built on narcissism. It is inevitable. You'll see Chinese women disdainfully rolling their eyes about American frivolity and arrogance even as they dab dry their Cosmopolitan splashed Hermes clutches and wonder why they are single in a nation infested with Y chromosomes. "The last guy I dated didn't even want to want to sex me anymore, let alone get a real job. Do I need to move to fucking Australia?"

Take a breath, Wildman, have a drink, the caps lock is on the left and I'm not going anywhere. Let me ask you more immediate question: not everyone in China has a TV.   What do you call it when part of a population becomes exponentially and suddenly more western while another part doesn't at all?

I'll save you the Google search: the answer is Iran.

Tell Sally Fields a happy mother's day from me when you see her tomorrow. I'm glad to hear she's doing good.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: China Needs More TVs

we're mad as hell

Sumner Redstone is the Chairman of the Board of CBS, UPN, Viacom, MTV, BET, half of the CW, and Showtime, and he is 86 years old and close to the end of his time. And woe is us. We're in a lot of trouble.

So, a rich little man with white hair may die. What's that got to do with the price of rice, right? And why is that woe to us? Because you people and 162 million other Americans watch TV. Because less than 3 percent of you people read books. Because less than 15 percent of you read newspapers.

Because the only truth you know is what you get over this tube. Right now, there is a whole, entire generation that never knew anything that didn't come out of this tube. This tube is the gospel, the ultimate revelation. This tube can make or break presidents, popes, prime ministers. This tube is the most awesome goddamn force in the whole godless world. And woe is us if it ever falls into the hands of the wrong people.

II.

And that's why woe is us that Sumner Redstone may die. Because this company could be in the hands of-- anyone. There will be a new Chairman of the Board sitting in Mr. Redstone's office on the 20th floor. And when the 12th largest company in the world controls the most awesome goddamn propaganda force in the whole godless world, who knows what shit will be peddled for truth on this network.

So, you listen to me. Listen to me. Television is not the truth. Television's a goddamn amusement park. Television is a circus, a carnival, a traveling troupe of acrobats, storytellers, dancers, singers, jugglers, sideshow freaks, lion tamers, and football players. We're in the boredom-killing business.

So if you want the Truth, go to God. Go to your gurus. Go to yourselves! Because that's the only place you're ever going to find any real truth. But, man, you're never going to get any truth from us. We'll tell you anything you want to hear. We lie like hell. We'll tell you that Grissom always gets the killer and that nobody ever gets cancer at the Baywatch house.

And no matter how much trouble the hero is in, don't worry. Just look at your watch. At the end of the hour, he's gonna win. We'll tell you any shit you want to hear.

We deal in illusions. None of it is true. But you people sit there, day after day, night after night -- all ages, colors, creeds. We're all you know.

III.

You're beginning to believe the illusions we're spinning here. You're beginning to think that the tube is reality and that your own lives are unreal. You do whatever the tube tells you -- You dress like the tube. You eat like the tube. You raise your children like the tube. You even think like the tube.

This is mass madness, you maniacs.

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===== ====== ===== The Last Psychiatrist: Cho Seung-Hui is Ismail Ax
I know nothing more about the case than anyone else with a FIOS connection, but for what it's worth, "Ismail Ax" seems like a gaming avatar. I know a lot of people are trying to link it to Islam, who knows, maybe, but if anyone out there is tight with the gamers-- especially True Combat and Battlefield 2-- or if you have a teenage son-- I'd ask around.

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===== ====== ===== The Last Psychiatrist: Cho Seung Hui: It's The Movies, Stupid

I still haven't had time to really look at this situation, but I have to address this nonsense about his psychiatric history: it's irrelevant.
He didn't do this because he was on Prozac, or he was Bipolar. Look at it the other way: are we going to say that people with bipolar are more likely to go homicidal? If so, should we do a Kansas v. Hendricks for bipolars? (in which the Supreme Court said it was ok to lock up pedophiles indefinitely, even in the absence of a crime, since "pedophilia" makes you a priori dangerous.)
If you want to really understand why he did it that way, you have to find out what article of media he was imitating. Take the photos, the manifesto, and google it until you find the movie the handguns came from; the book (or comic book) the manifesto came from. He didn't come up with this stuff on his own, he is imitating something. For Klebold and Harris it was the Matrix and Doom. What movie is he imitating? Find it.
Because it isn't about mental illness, or genetics. It's about identity, it's always about identity, and sometimes the identity you choose doesn't work out that well. So, emergently, you grab an identity which has appeared to work-- you imitate a movie, a game, a comic.
I'm not saying movies made him do it; I'm saying he was looking for an excuse to do it, and he went through the usual catalog: movies, comics, games. Come hell or high water, he was going to kill someone. But in terms of prediction, the operative question is, if this guy goes homicidal, how will he do it? He didn't strap explosives to his chest, not because it wasn't available, but because it didn't match the identity he wanted to have-- that he got from a TV show or movie.
Ismael Ax, handgun to the head, hammer cocked like a bat to the right, knife to the neck-- all those stills from his video clips you see on CNN aren't random, they're a specific imitation of something else. Find the thing he was imitating, and you have found him.
Because he didn't exist, that's the problem. He picked an identity, and no one liked it, it backfired- no chicks-- so he moved to plan B: pick an identity that absolves him of the guilt of shooting 30 people.
Stop looking in the DSM. Start looking in IMDb.

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===== ====== ===== The Last Psychiatrist: Christmas Break

I'm off for two weeks, taking the opportunity to upgrade the computers/monitors and plan my next move. I will also be starting another blog under another alias. I'll reveal it as mine if it takes off.
Also, to all those who emailed me about the Time Person of the Year post: thanks; it wasn't Photoshop but MS Paint; I have nothing against Grossman at all, I loved his King piece, the piece wasn't about Grossman, it was about us, society, our purposeful alienation from each other; I changed the screen to blue to reference the Blue Screen of Death; no, "Go Fuck Yourself" wasn't supposed to be (only) mean, it was a double entendre: narcissism--> self love--> "Go Fuck Yourself."

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===== ====== ===== The Last Psychiatrist: Christopher Columbus Was Wrong
And what you think I'm going to say next reveals your educational and political biases.

I.

Asked another way: If I say Columbus was wrong, then who was right?

Contrary to popular belief-- a belief caused by every American grade school textbook from An American Pageant to Prentice Hall Earth Science, no one in Christopher Columbus's time thought the earth was flat. It was established information, since the ancient Greeks, that it was a sphere. Eratosthenes calculated the diameter to 10% accuracy back in 200 BC. Ptolemy (0 AD?) knew it was round, but thought the sun (another sphere) revolved around it.

And yes, even the Catholics believed it was round, too. St. Augustine knew it was round, his difficulty was accepting whether there were any people on the other side of the world-- how do you know it isn't all just water?

So the dispute was not whether the Earth was flat, but how big it was: most people thought that it was bigger than it actually was, and Columbus thought that it was much smaller than it actually was.   Turns out even Columbus didn't really believe it was that small either, as he fudged the ship's logs so that the crew wouldn't know how far they'd actually gone, and mutiny.

Either way, the Dominican Republic was in the middle, and no one expected that.

So Columbus was wrong about how big it was. The prevailing estimates were closer to the truth.

II.

Some of you might have assumed my initial question was of the variety, "Did Christopher Columbus discover America?" or "Did he think he made it to India?"

What's interesting about those questions is that they are not fact queries, but political alignments. It is a fact he discovered America-- he didn't know it was there. It is also a fact that others had been there before him, and people were indigenous to it, as well; but these are not mutually exclusive facts.

And people love to jump on the question, take sides: "no, no, he didn't discover it, Leif Erickson/the Chinese/Indians!!!" But they're not correcting misinformation; they're debating prejudices. They're not taking sides for something; they're taking sides against something.

Anyone who tells you Leif Erickson discovered America is unlikely to know any other fact about Leif Erickson. Not the date of his voyages, his country of origin (Viking is not a country) or what he was even doing that far west in the first place. Nothing. They don't care about Leif; they just want Columbus to be wrong.

Why that is could vary: maybe it's a slap against the establishment, their parents, "everything my Dad told me is wrong!" as they take a deep drag from their only true friend. Maybe they want to appear smart. Or possessing of a trendy anti-european sentimentality.

What matters here is why such a meaningless debate is the one most people want to have; yet the other, more urgent one-- are we even being taught anything correctly in school?-- passes without even a thought.

III.

So why is it we were taught that the prevailing opinion was that the Earth was flat and that Columbus's crew was terrified they would fall off the edge?

The most common answer is Washington Irving's (yes, that Irving) book The Life and Voyages of Christopher Columbus, a fictional account, which assumes a prevailing belief in a flat earth.

Trouble is, most people have never heard of this book, let alone read it; to blame it for generations of misinformation seems, well, a stretch.

But the flat earth misconception does indeed appear in textbooks. The problem comes down to this: no one cares enough to fix it. Parents learned it; kids learn it; and even if you do discover the truth (e.g. now) it's simply not worth going back (to whom?) and fixing the source (e.g. the textbook.) The correct information becomes a novelty, bar talk. The factual information supposedly has no value.

Yet the debate about who discovered America-- that somehow matters. The incorrect knowledge makes medievalists look like religious idiots-- that's ok. That it alters your hazy guess about what life was like back then-- no problem. That it supports the idea of history being divided between now and pre 1980-- awesome.   Secular humanism is the name of the game, and that also means no special place can be afforded to any Italian/Spanish explorers.

How do generations of Americans get the basic facts so horribly wrong? No one reads primary sources, and, worse, everyone relies on the same bunch of interpretations of primary sources. Then the debate is not about the the accuracy of the information, but the presence or absence of a political biases.

We got what little information we have about history from the same few sources; no wonder we don't know anything, and we all don't know the same things. Imagine if we all got our news from the same few sources, or our medical information from... oh, wait.

In other words, it's the same way we practice medicine and pick our Presidents-- More of The Same vs. Less Of Everything. And it doesn't seem likely to change.

-----

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===== ====== ===== The Last Psychiatrist: Cinco de Mayo Is Not Mexican Independence Day
(from Wikipedia)

History

In 1861, Mexico ceased making interest payments to its main creditors. In response, in late 1861, France (and other European countries) attacked Mexico to try to force payment of this debt. France decided that it would try to take over and occupy Mexico.

WSJ: Did December Ever Happen?

What else ended in November and started in January?

On September 21, 2008, Goldman and Morgan Stanley changed their status from investment banks to bank holding companies-- and thus submitted themselves to the oversight of banking regulators and the Fed.

So December went missing with the government's approval. The same approval that allows the release of earnings that are of the form: "if you exclude our losses, we're making a ton of money."

When this earnings season ends, I would recommend being no where near a stock market. Cinco de Mayo seems an excellent time to sell.
===== ====== ===== The Last Psychiatrist: Clarification On What Goes Wrong In A Psychiatrist's Family

Many interesting and varied reactions to my post, "What Goes Wrong In A Psychiatrist's Family?" It struck a nerve with a lot of people, and others couldn't relate to it at all. But I would like to clear up one element:
It's not that even handed, calm, unemotional criticisms directed only to the child's behavior is wrong; it is that no one does it well. And that's where it all falls apart.

SOME psychiatrists think/try to do something noble (criticize behavior and not the child itself) but they are HUMAN, and get tired. They will eventually get angry, and, from a kid's perspective, when the parent gets angry is what matters. What did I do to piss Dad off?
The opposite of this, call it the non-psychiatrist parent, is calm, then gets a little angry, a little more angry, a little more angry, then yells, screams. There's a build up. A few years of this and you realize that there are some things that make Dad a little angry, and other things that make him really angry. There's normal, varying levels of human emotion to different situations.
But the child of a psychiatrist doesn't get that. He gets binary emotional states. "Lying is not acceptable behavior." Later: "Yelling loudly is not acceptable behavior." Later: "Picking you nose is not acceptable behavior." Later: "Stealing is not acceptable behavior." What's the relative value? A kid has no idea-- he thinks the value is decided by Dad, not intrinsic to the behavior. "Eating cookies before dinner is not acceptable behavior." Later: "Kicking your brother is not acceptable behavior."
Ok, now here it comes:
After seven or eight or twenty five "not acceptable behavior" monotones, Dr. Dad can't take it anymore; he explodes. "Goddamn it! What the hell is the matter with you?! What are you doing?!!"   All the anger and affect gets released, finally. The problem-- the exact problem-- is this: the explosion of anger came at something relatively trivial. Maybe the kid spilled the milk.
So now the four year old concludes that the worst thing he did all day was spilled the milk-- not kicking his brother, or lying, or stealing. Had he not spilled that milk, Dad wouldn't have gotten angry.
Add this up over, say, a year: mostly flat, neutral monotones, peppered with unpredictable yelling patterns, inconsistent explosions, and now the kid can't form a hierarchy of good and bad. In fact, what he learns is that good and bad are defined almost exclusively by the reaction he gets from others (e.g. Dad) and not the behavior itself.
You say: but the kid's not an idiot, he's going to know that stealing is worse than spilling milk. Well, how is he going to learn that, except from you? You say: just going through life-- every kid eventually learns it. Yes, they learn that it is worse, but not why it is worse. The conclusion is that the hierarchy of bad and worse is determined by the severity of people's reactions.
You say: the solution is that Dr. Dad needs to work on maintaining his calm all the time, and not exploding. Well, it's not going to work: he's human. Eventually the electric bill will be too high, or his wife cheats on him, or he has the flu, or he's stuck in traffic all day. And he'll explode (or, the alternative: check out. "I'm not dealing with this anymore.")
Consider this: a kid knows exactly how his father feels about a certain patient, or colleague, or friend, because he sees a consistent and predictable reaction in the Dad every time the person is mentioned. But the kid does not have that clear link for himself. There's more informational affect from Dad talking to a patient on the phone then there is when punishing you.
Contrast this with the reaction of, say, a hypothetical "angry Dad" who has six beers a day after work: he's always pissed off. Always. Even though he flips out over spilled milk, he flips out over everything. The consistency of his anger makes the anger attributable to him-- "Dad's insane"-- not to you or your behavior. You don't infer from this that what you did is good or bad-- you'll have to learn that elsewhere.
But just as you've identified Dad as "Angry Dad" you might also infer that he hates you, that you are a bad person. This is clearly not a good thing, but the point is that you develop an identity from it, you get defined (though negatively.)    The inconsistency of the psychiatrist-parent's anger is confusing; why this thing, and not the other thing? Why so much consistent (same kind and amount) affect talking to an auto mechanic, and so little affect-- especially consistent affect-- with me?

So you have a psychiatrist-parent, who works long hours; who tries hard to be neutral even in punishment; who gives little in the way of emotional information about a kid's identity, but is so obviously clear about other people; who once in a while explodes, inconsistently, over unpredictable things.
Here it is again, where it all goes wrong: the child develops an identity which is about the reactions of others. "People's opinions of me are based on how I make them feel."
Disclaimer again, and for the last time: not all children of psychiatrists go insane, not all psychiatrists suck as parents, I don't know what I'm talking about, Bush lied, etc, etc. Please understand I am not criticizing psychiatrist parents, I'm trying to understand something.
You come home, and find your kid has spilled the milk. How do you react? Ok, now ask your kid: how do you think I'm about to react? The answer, ideally, should be the same. If it's not, you've got a problem on your hands.

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===== ====== ===== The Last Psychiatrist: Clinical Experience vs. Clinical Trials

In CNS Spectrums, Dr. Rosenheck takes Dr. Marder to task for his suggestions that CATIE results are limited and flawed, and clinical trials may not be better than clinical experience.

The article must be very important, because it is labeled as a Communique, yes, just like the one that called for the normalization of relations with China and decreasing arms sales to Taiwan, which brought us the Beijing Olympics 2008. Thanks, Mr. Nixon!

He offers a detailed response to Marder's criticisms of CATIE, and quite effectively defends CATIE's results of "no health advantage for [atypicals] over older" drugs.

Many examples have emerged in recent years of costly and painful treatments that were deemed on the basis of clinical experience to be self-evidently effective--until double-blind studies showed them just as clearly not to be.^16,17

What's awesome about that sentence is that the references are books about alternative medicine and why we make irrational decisions. Is that really the best he could come up with? Why not mention, say, Depakote?

The bias-- for him and most du jour psychiatrists-- is that research shows that new things are not as good as we thought, and we should change our behavior accordingly. What about when research shows that they are better than we think? Does that change our behavior? CATIE showed that Geodon worked as well, but caused less weight gain than the others. But I'd wager good money Rosenheck prescribes very little Geodon in comparison to other atypicals. So much for science.

While clinical experience must guide care of individual patients and the development of public policy it can not replace experimental research as the fundamental source of legitimacy of clinical medicine, and within it, of the profession of psychiatry.

That's not fair, let alone rigorous. You're taking the research and coloring it with your own "experience."

Here's an example: CATIE found that the newer drugs were no better/worse than the older typical agents. Ok: so why can't I just use only the newer meds? Why does CATIE mean I should go back to typicals?

Oh: cost. Was cost a relevant factor in the CATIE analysis? I missed that page. And are you asking doctors to actually consider cost as a factor in prescribing? Why? What part of their awesome medical training allows them to make economic and policy risk/benefit analyses? They are not all that good at medical risk/benefit analyses, I should remind you.

And if we all agree that doctors should consider cost, then shouldn't they consider the whole cost? Not just Geodon's cost, but it's impact on hospitalization, on polypharmacy, food costs, cost of (not) needing a cardiologist, etc. Fortunately all these things were explored fully in CATIE. (/sarcasm)

In other words: if doctors are going to be thinking about money, they should be handling the budget. Every patient gets $20/d pharmacy budget. Go.

One final observation: Rosenheck derides clinical experience, but what he cannot see is that, as an academic psychiatrist who primarily does research, studies are his clinical experience. As suggested above, he does not apply them formally or objectively, but instead picks and chooses what studies or results he thinks are important based on an internal barometer that has nothing really to do with science (e.g. Geodon, above.)

In other words, the application of clinical experience and the application of clinical trials are flawed in the exact same way: strongly subject to selection and confirmation bias.

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===== ====== ===== The Last Psychiatrist: Clozaril: FDA Misses The Point, Again

As you may know, when prescribing Clozaril (clozapine), a complete blood count with differential (CBC w/ diff) has to be checked every two weeks, because of the risk of agranulocytosis.
The FDA has relaxed these requirements: now, you have to check weekly for the first six months; then every two weeks for six months, then only monthly after that. You have to show WBC >3500/ml, and ANC>2000/ml. (That's white blood count and absolute neutrophil count.)
Don't think for a millisecond this was done because the FDA did a rigorous re-evaluation of safety data.   This is the FDA that black boxed antidepressants for suicide and antipsychotics-- oh, sorry, only atypical antipsychotics, even though typicals are as bad, if not worse-- for death in patients with dementia related psychosis.
What's stupid about this is that agranulocytosis is the least of anyone's problems. In the Clozaril National Database (1990-1994) (1), there were 99,502 patients. 382 (0.4%) got agranulocytosis, and 12 died (that's 0.001%). The number of clozaril related deaths (all kinds) was more than 400.
In an Italian study, the rates of neutropenia are about 0.9%, and agranulocytosis 0.7% (2)
They are, however, dying in not insignificant numbers by other things.
Consider a Maryland finding: of the 2046 clozaril patients from 1990-2000, three died of new onset diabetic ketpacidosis. (0.15%) None had had diabetes. (3) Or the Israeli study (4) that found that 4/561 clozaril patients had sudden death-- 10 years younger, healthier, and 4 times the rate of  non-clozaril treated sudden deaths. NB: no one died from agranulocytosis.
How about myocarditis: 8000 patients over 6 years: 15 myocarditis, 8 cardiomyopathy; 6 died. That's 0.3%  5 of the 6 deaths occurred in first month (that's right: month). (2) Given the rapidity of death, the authors speculate it's an acute hypersensitivity reaction (i.e. IgE/Type I).
A review of Pubmed/MEDLINE from 1970-2004 found rates of fatal myocarditis/cardiomyopathy to be between 0.015% and 0.188%.
An oft cited article by Walker examined 67072 clozapine patiens from 1991-1993, and found that of the 396 deaths, the most common cause was pulmonary embolism. (FYI: Zornberg found that exposure to low potency antipsychotics massively increases the PE risk to (OR 24 for low potency, 3 for high potency; not dose related, usually occurred in first three months.)
In contrast to Hagg's finding of 12 cases of PE/DVT, and a frequency of about 0.03%, another study of 13000 inpatients over 6 years found 5 PEs, i.e. a rate of 0.038%; but this was no different than typical neuroleptics of non-treated.
Look, I'm not saying to ignore agranulocytosis. I'm saying that when your patient's heart explodes, you can't say, "but the FDA only said CBCs!" You need to be checking EKGs. And when the lawyer asks you how most people die when on clozapine, it'll look really bad when you give the wrong answer.

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===== ====== ===== The Last Psychiatrist: CNBC Ratings And VIX Predict Rum Sales

(Original idea here.)

     Pearson's r = 0.943, that's amazing.
     Maybe CNBC viewers are exhausted. But they're checking out, and if Professor Pearson has anything to say about this, VIX has to fall very soon.
     FYI, the VIX is at the highest point in 20 years. Remember 800. It is inevitable.
I'll write something funny, maybe about narcissism, for you all on Saturday. You know, to go with the rum.

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===== ====== ===== The Last Psychiatrist: CNBC Ratings Seem Correlated To Future Market Volatility

Following up on a crazy idea I had earlier.

The floating pink between 8/11 and 8/22 is CNBC's airing of the Olympics, which skews the data. Ignoring that, you can see a pretty clear relationship between CNBC's average daily ratings and market volatility (VIX). It also appears that the ratings anticipate the VIX by two days, or so.

I only have CNBC ratings to Friday, 9/26/08; but I have VIX data for the next two days. 9/29 was Black Monday, Dow -777.

These two are highly correlated. Starting from 8/23/08, the Pearson's r is .889, which, if remember my college statistics, is way better than a sharp stick in the eye. (If anyone out there knows a better test to use, please let me know.)

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===== ====== ===== The Last Psychiatrist: CNBC Ratings Predicts Bailout To Pass, VIX To Fall

Pearson's r=.929

As it appears CNBC ratings anticipate the VIX, then the VIX should fall today or Monday, and the only way I see that happening is that the bill gets passed. Since the folks at trader-talk.com seem to like me doing this, I'll make it a weekly thing.

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===== ====== ===== The Last Psychiatrist: Comedians Tosh, Gaffigan and Hedberg for Narcisissm

I know, I said I was going on Christmas break. But what better time than the holidays to focus on narcissism?
After thinking about how marketers target our narcissistic leanings, I wondered if other groups did the same. Stand up comedy seems also to have followed this path. Most of today's main comics do what I call meta-comedy; they tell jokes, but then also deconstruct the process of joke telling, right there, during the act. They comment on the act. Here are some examples:

Jim Gaffigan (outstandingly funny) has two parallel joke streams in his act: in the primary stream he makes jokes, and in the secondary stream he affects the voice of an uptight, perplexed female audience member and comments on the jokes he just made:
You can't have cake for breakfast. Unless it's a pancake. How'd that slide through? Young man, you're not having cake for breakfast, you're having fried cake with syrup for breakfast. Now load up on that and try not to nap. Pancakes definitely make you lower your expectations. Well, look's like I'm not showering today. (pause) This guy talks a lot about cake. [Then on to jokes about birthday cake.] If he does another cake joke, I'm going to kill him.
[finishing a joke about Hot Pockets and Nascar]... hey, I like Nascar. He's a jerk.
[a series of jokes on holiday traditions, then finishing with a joke about Mr. Rogers:] Remember that from Mr. Roger's? And they wonder why we do drugs. Oh, that was negative. How about those traditions, fellow. Why don't you go back to that? [and so he jokes about Valentine's Day and about eating something from the heart-shaped "gamble chocolates:"] Oh, that was really nasty-- I'm going to have to eat nine more to get rid of the taste. (pause) That joke didn't even make any sense.
If you hear his act (not just read it) you'll hear how the sidebars of the "commenting woman" are as funny as the main jokes, and are not incidental-- they form a necessary part of the routine. They function as brief pauses of concentration to relax the audience, and relieve some of the pressure off the main jokes-- even if the main jokes are not that funny, the sidebar can give them meaning as something to be commented upon. Thus, even jokes that are not funny can be made funny by commenting about them. (But NB: they're all pretty funny.)
Some comedians explicitly state that they are doing an act; there is no suspension of disbelief that the entertainer is telling a "true" story. The comedian lets you know this is fake, constructed, but still funny:
Daniel Tosh (hilarious) on Tourette's:
Do you think there's one case of polite Tourette's in the world? One person, who yells out random compliments for no reason at all? Nice smile! I'm sorry ma'am, I have a disease.... Lovely hat! I think two examples is enough-- next joke.
And on changing Daylight Savings Time:
I'd like to change Daylight Savings Time-- are you ready for this? Hold on Irvine--(pause)-- I put whatever city I'm in right there so it feels more local... (etc)
...[it's not fair, especially to] the people who work at night-- 1/3 of this country according to a survey I just made up for this joke...
The main joke is funny, but it's funnier because he has allowed the audience into the process.
Another example is the terrifically funny Mitch Hedberg, who does a Steven Wright-esque routine of short, independent jokes ("Every book is a children's book if the kid can read.") But different than Wright, he also references himself as a comic, and tells you how he feels the set is going:
Mitch Hedberg
I think a gift certificate is a bad gift. What's a gift certificate? You take money that was good everywhere...(a lot of laughter/cheering from the audience; he, too, starts laughing) You took a little long on that clap. I had some extra lines, but now I can't do them.
On writing jokes in his hotel:
I got to write these jokes. So I sit at the hotel at night, I think of something that's funny and then I get a pen and I write it down. Or, if the pen's too far away, I have to convince myself that what I thought of ain't funny.
It is common for Hedberg to judge his own jokes ("that joke was dumb, I'm aware of that") or talk about how he tells jokes ("I have monitors [today], thank God, because last night I didn't have them and I was telling jokes, and I had no idea what joke I was telling. So I told jokes twice. I even told that joke twice") or accept joke requests from the audience ("cherries joke? Wait, you mean the cherry--? Ok-- I heard a guy tell me he liked cherries. I waited to hear if he was going to say, "tomatoes," then I realized he just liked cherries... that joke is ridiculous." He also jokes about taking the laughs he gets from one joke and using them on the CD for jokes that didn't work.
The comedians themselves aren't narcissists; they are tapping into the narcissism of the audience. The audience is attracted to these comedians because they get brought in, they get to feel like they are part of the comedy, part of the process, part of the act-- they are behind the curtain, behind the scenes. They're not the performers, but they could be; and at least their close confidants, and that's a start.
This meta-comedy is appealing because by being brought into the process, audience members are permitted to believe that what separates them from being the main act isn't hard work, or talent, but being noticed, being selected, getting a break. I could so do Mitch's act. Howard Stern is also like this. Few people think they could be disk jockeys, but almost everyone thinks they can do a 4 hour morning show. And they think this because Howard has brought them into the process of a morning show. So you feel like you've already done it, you know the tricks of the trade and you're good enough. But you're not-- you're just narcissistic.
To follow the evolution of this process, go back to the previous leader of comedy: Jerry Seinfeld. Certainly, his show "about nothing" was about himself, his (feigned) narcissism. It was the unimportant minutiae of his life blown out of proportion: he was the main character in his own show. But today's comics play on our desire to be main characters, first in their shows, but of course ultimately in our own.

I used to hear people repeat Seinfeld's jokes, but it was funny precisely because we all had a shared experience of them. But nowadays I hear people use a Hedberg joke as if they came up with it-- because they could have written it. They could be comics, too, if it wasn't for the wife and kids. Mitch wouldn't mind, anyway; he's a friend.

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===== ====== ===== The Last Psychiatrist: Competency to Be Executed

If society has determined that a right to commit suicide does not exist, can a convict sentenced to death waive his appeal?

First, consider the legal standard for such a waiver: you have to be competent to do it. Competency is defined by Dusky v. U.S.: do you have a rational understanding of the charges/issues; do you have the ability to aid in your own defense (i.e. work with a lawyer.)
It should be obvious that if you were competent to make it through trial, you probably meet both criteria. Indeed, Justice Powell, in Ford v. Wainwright speculated that competency to stand trial likely presumes competencies for execution. (But the Court ruled that a formal review is needed in these situations.)
And, many do waive their appeal-- for various reasons. Possibly some accept their guilt. Some may have other reasons for dying: prison sucks; they're depressed; etc.
The trick of this question is that the appeal is not for the defendent, it is for society. It is to ensure that the death sentence is appropriately used (not excessive, prejudiced, etc.)   So in some states, a defendent does not have the right to waive his appeal; appeals are required by law.
So waiving an appeal is not a right anyone has; this is not to say it can't happen-- it's just not your right to do it, it is an option allowed to you after careful review. The primary (competency) standard is whether the waiver is "knowing, voluntary and intelligent." It seems logical to infer that the "intelligent" can only mean an acceptance of your guilt and the punishment as appropriate; but this also presupposes that you are factually guilty (you can't think your punishment is appropriate if you didn't actually do it).
Note, therefore, that statutory appeals and the absence of a consitutional right to waiver are consistent with the idea that no one can be competent to commit suicide (and we will leave out the case of terminal illness (which, some argue, is identical to the scenario of execution.))
There's a byproduct of this. Can you be incompetent to be executed? If you are incompetent to stand trial, trial gets postponed. Does your execution?
The typical test for incompetency to be executed is (using Texas as an example; they execute the most people) if the defendant does not understand 1) they are to be executed, imminently; 2) the reason they are being executed.
You can see that nowhere in this test does it ask if you are psychotic, or think you are immortal. If you say, "they want to execute me on Monday because they think I killed that girl, but really it was aliens that did it, and besides, I can't die because God will protect me-- in fact I wish we would do the execution today because I want to bring about the Rapture" then you are competent. (However, in this scenario, you wouldn't be able to waive your appeal.)
I emphasize this point-- the absence of any psychiatric tests-- because otherwise we have what happened in Texas in April of 2006: The judge thought Steven Staley was incompetent to be executed-- experts had said he was too mentally ill-- so Staley was sent back to the prison psychiatrists to be forcibly medicated to restore him to competency-- to be executed.
This puts doctors in the bizarre ethical quandary of treating someone to kill them.
Sell v. US made it explicitly ok to forcibly treat someone to restore them to competency to stand trial, because otherwise (remaining incompetent and postponing their trial) violated their constitutional rights to a speedy trial, etc. But this ruling, in my opinion, therefore made questionable whether you could forcibly medicate people for any other circumstance except competency to stand trial.
But it is pretty obvious to me that trial competency requires a considerably higher degree of cognitive function: it's more than just knowing something, you also have to be able to rationally manipulate information and assist in your own defense. Execution competency requires none of this, just a binary, yes/no understanding of two questions. And therefore, it is a rare case that the forced administration of antipsychotics would get a person to answer these two questions.
Keep in mind that they made it through a trial-- in my opinion, they met a higher competency standard. So to say they are incompetent to be executed means they must have become sicker after the trial was over.
I'm not debating the morality of the death sentence. I'm pointing out that involving psychiatry at the execution stage virtually guarantees the execution will not take place. If you somehow decide to say that someone is too mentally ill to be executed-- if you go that far-- then I can forsee almost no circumstance ever that the person will become competent. It is likely unethical to force medicate someone to be executed; and even if they were, what doctor is going to be sure-- go on record-- they have improved enough?
Many are going to disagree with me. They'll say that Ford is really about (moving towards) prohibiting the execution of the mentally ill (not just the legally insane); in the example above, since the person thinks he is immortal, he would not actually understand the ramifications of execution, so could not be executed. We can debate this all day; I stick to a strict reading of the test because the alternative puts doctors in the position of deciding who is to be executed.
I've written about doctors staying clear of social policy issues, and this is a good example. The decision to execute is society's through the legislature and via the judicial system, not doctors' as the philosophe-proxies of the apathetic bourgeoisie. Doctors are nearly the worst deciders of justice imaginable (and rightly so, as the practice of medicine inherently precludes its application.)

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===== ====== ===== The Last Psychiatrist: Competency To Commit Suicide?
You knew this was coming, right?

A patient with a pre-existing living will ("no life support, no intubation, no blood products") attempts to OD, is brought to the ER, and requires intubation to live.    So now what?
What makes this situation needlessly complex-- i.e. it is actually quite simple-- is two major misunderstandings.
First, questions about living wills are only appropriate in cases of irreversible, terminal illness. In other words, if a person has a notarized living will saying no intubation, can they get temporary intubation to stabilize them, with the expectation that they will survive and go on with life? Of course. So that a living will exists is mostly irrelevant unless we are dealing with irreversible, terminal illness.
Generally, suicides lack capacity to make decisions about life saving procedures; we assume that psychiatric disease is impacting their ability to make rational decisions. Substituted judgment, as the standard, can be here interpreted to mean "what the patient would want, now that he has damaged himself through a suicidal act, but if he was now also free of psychiatric disease." So it's possible that free of depression he might still actually want to die; but in non-backwards cultures (gauntlet thrown down!) we assume this is unlikely.
Second, there's quite a bit of confusion on what a living will actually is. It's a type of advance directive (not the other way around.) It's a document to be read and interpreted by one reader, the surrogate decision maker. Period. Not the doctor, or the Ethics committee, but the surrogate.
This sounds confusing, because it is typically the doctor who reads the living will-- but that's because generally there isn't a dispute, and the doctor actually becomes the surrogate. But what if there was a dispute? What if the wife wants him alive?
Consider Florida: if a patient has a terminal illness, and if there is no surrogate available, the doctor can proceed according to the living will. But-- and this is the big but:
If there is a dispute or disagreement concerning the attending physician's decision to withhold or withdraw life-prolonging procedures, the physician cannot proceed pending an expedited judicial review.
(Within seven days.)
In other words, either the potential surrogates AND the doctor agree with the living will, or you go to court. Or: just because there's a living will, doesn't mean you get to do what it says, over the objections of anyone.
The other type of Advance Directive is the power of attorney. Usually legally specified, the spirit still remains an appointed surrogate who will interpret the living will: family members, etc.

So now, in the above scenario, we have a situation where a living will is to be interpreted by a surrogate (say, the wife) in the spirit of "what he would have wanted if he wasn't so depressed." I think you see the difficulty that arises, and why, the obvious, easy, and likely only legally defensible maneuver is to treat aggressively, psychiatrically stabilize, and debate later.

In difficult questions, it can be useful to get guidance from areas that have direct stake in the matter.
Most life insurance policies are invalidated in suicide. This would include a living will/advance directive withholding of life sustaining measures following a suicide attempt, even if this took place years later. In other words, the fact that doctors, et al, decide the patient "has capacity" to die, insurance companies are not bound by this.
For you all with strong opinions on the abortion question, here's a noodler to show you your inconsistent logic: should a terminally ill pregnant woman by allowed to invoke a living will and end life sustaining treatment? If you say yes, then you must also agree that abortion is ok; if you say no, then abortion can't be ok (otherwise, why are you forcing her to stay alive?)
In most states where abortion is prohibited or restricted, a pregnant woman may not invoke a living will-- by virtue of being pregnant, all measures will be given over the objections of the woman, unless they don't help the baby and are actually harmful to the woman (i.e. you can't hurt her to keep her alive.) (P.S. the State is obligated to pay for all costs if insurance won't.)
Here's the homework question for this week: If our society has determined that there is no right to suicide, can a convict sentenced to death waive his automatic appeal?

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===== ====== ===== The Last Psychiatrist: Congress Has Its Say, And It Says, "Hey, Did You Cashew Shells Loan Out All The Money We Told You Not To Dare Lose Any Of?"

If I told you you were allowed to spend $1.5 trillion dollars to fix the planet, would you then go take an 8 month nap?

In the House hearings/whippings of the CEOs of the banking industry, Rep. Gary Ackerman (D, NY) rises to the occasion.

A gourmand of self-righteousness, he says he hears from the CEOs that the banks are lending: "we listen to you and we hear words, words, words and no answers. It seems to me and some of us that this money hasn't reached the street - that you're not loaning it out." What did you do with all the money? Jamie Dimon, CEO of JP Morgan, tries to give him a primer on banking and mortgages, but he doesn't want to hear it, he wants to pretend he's Law and Order, interrupting with the pointed questions. "Can you tell us what you did with $25 billion [of TARP money JP Morgan recieved]?"

And to further display his ignorance, he adds, "not what you did with all your other money, just that $25 billion." As if the money is separated somewhere. His and hers bank accounts.

Then he asks, "Why can't people get mortgages?" That's it. He means of course, why aren't you out there giving people mortgages? What, to anyone who needs one?

Dimon: We did $35 billion in mortgage originations [in 2008].
Ackerman: What did you do the year before?
Dimon: Approximately the same.
Ackerman: So with $25 billion more, you gave out the same amount? There's no increase.
Dimon (while having a stroke): But...
Ackerman: If you did $35 billion last time, you did $35 billion this time, we gave you $25 billion more to do it, nothing went out then.

They must not have holes in New York. The reason they got $25 billion is because without it, they would have lent out zero.

Of course they are hoarding the cash, tightening lending standards. They want to stay solvent. Or would you prefer they take TARP money and then go bankrupt? Are bank deposits up?

Businesses want lines of credit, but what if they can't pay it back? Hell, what if they actually tap their line of credit-- that's money the bank no longer has that it needs to keep up adequate capital ratios.   They don't want to lend, they want to hunker down and ride out the recession.   Does Ackerman want them to lower the standards, lend to everyone who needs it-- with the taxpayer money?

Some of these banks are completely insolvent, no amount of money will get them to increase lending, the hole is too big and it happens to be on top of an even bigger hole.

II.

But all this is beside the real point, which is this: You might know how banks operate, that $25 billion in TARP is not automatically lent out, but he is supposed to know. That's why he's there.   No one expects him to have been a finance expert before all this started, but he is supposed to be a finance expert now, that's his job. But he didn't bother, he didn't think he needed to, he has his crazy paradigm that he's sticking with, wrong or not. It's like a doctor who chooses not to learn about a new medication because "I'm comfortable with what I already know."

He authorized $800b, gave out $300b, and never once investigated how money gets used.

Worse than ignorance is that what he and Congress want are entirely contradictory things: on the one hand give out loans to prop up the economy; on the other hand, stay solvent and don't lose the taxpayer money we're giving you to loan out to everyone; on the other hand, you jerks loaned out too much money.

Another Congressman actually looked at these CEOs, and said, "I don't have much personal experience with bankers, so I rely on my impression of the old, conservative banker, like Jimmy Stewart." That's how he imagines the banking system operates. Fine, now that you know it doesn't work that way, could you at least go look up on Wikipedia how it does work? Before you say we need more bankers like George Bailey, remember that he almost committed suide, and what saved him wasn't a sense of duty to his family or a desire to atone for his life's mistakes, but an angel. Maybe an angel will buy up toxic CDOs?

That these men can be in Congress so long yet still be so ignorant not just of basic finance but of current events-... can anyone expect Congress to do the right thing, even assuming noble intentions, given that they do not understand what is happening and do not not feel any obligation to find out? But they don't need to know all that new-fangled finance. They're like Mike Birbiglia's mother: "I'll fax this to you, but you'll have to fax it back when you're done, it's my only copy."

III.

One more thing: would everyone please stop saying the we, the taxpayers, are on the hook for all this money? We're not. Have your taxes gone up to cover all this spending? It's no different than before, we want something for nothing, we want the lifestyle we deserve, not what we can afford. Our time horizon for anything is our lifespan or less, never about the next generation. "They'll have to find their own way." How? You're not leaving anything behind.   I have not met one person ever who was thinking in terms of saving enough to leave their kids something, anything, some legacy. People barely think in terms of retirement, let alone dynasty. Which is how we all got into this mess, and why we will not get out for another half-generation.

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===== ====== ===== The Last Psychiatrist: The Contagion Is The Solution

wait... why can't I talk to anyone?

Seen Contagion yet? Here's a simple question: can you name one character?

Not the actor's name, the character's name. Take your time. Nothing?

A=A, and character driven movies, the kind Soderbergh is famous for, are supposed to be about characters.

Maybe this isn't a character driven movie. Maybe it's a documentary, aTraffic-style story about "what would people do if?"

But the movie doesn't depict them doing anything you wouldn't predict (die; panic; kill each other; attempt to profit; mourn; protect their own at all costs) or in a new way. So characters you're not emotionally involved in, doing nothing unusual... what's this all about?

I.

This is the opening scene:

Gwyneth is not driving, but is still holding a phone, unnaturally, with her left hand. Is she a leftie? No. Did she have a stroke? No. Look closely, she's married. Two ways to go with this: either this is a disaster movie about grief, or a disaster movie about about punishment. Well, she's calling from an airport and the guy on the phone isn't her husband. The hell you say?! That's right, she's having-- and this is a quote-- a "layover."

Soderbergh obeys the Rule Of Thirds

So maybe this is like a horror movie: sexual sin= horrible punishment; a subtext which is repeated later as her husband, Matt Damon, tries to protect his pretty-but-not-hot (=survives) teen daughter from her urges to be with her who-knows-if-he's-infected boyfriend. (The script which I did not find on The Pirate Bay maybe says her name is Jory, BTW, but the audience doesn't care.) Is it the virulently contagious virus Damon's worried about? Sure it is. That's why he pulls out a shotgun when he catches them after 15-900 minutes of close contact frolicking in the back yard. Jory looks flushed. He finally relents to the inevitability of penis and vagina at the end of the movie when boyfriend shows up at their house wearing the vaccination bracelet. Safe sex. Matt Damon smiles as they dance with each other, then walks away, I assume into oblivion. That's what single dads are good for, cuckolding and pass interference, and don't let the door hit you on the way out.

Back to the inception. Gwyneth is infected but she doesn't know it, and is shown partying in a Chinese casino, blowing on men's hands, and forgetting her sin phone at the bar, which a Ukranian model (=blonde harlot) returns to her, thereby ensuring all sexualized blondes are punished.

But not before their sins are visited on the son.

And being an American, you say, "wow, they killed a kid in a mainstream movie?" Quite gruesomely, I might add, but don't worry, you'll feel nothing. He wasn't really a kid, he was merely an extension of her (he was only Damon's step-kid, making Matt twice a cuckold), and he needs to die to free Matt Damon to return to his real daughter.

When a disaster strikes, the answer to "why?" is usually of the form, "endocytosis of the virus into the cell" or "plate tectonics and subduction zones" which is as satisfying as an imaginary bottle of rum. So we convert it to a narrative, a story, yes like a movie and yes like 9/11, to which the answer is always 100% the same: punishment for guilt. The only question is whose.

Gwyneth is Patient Zero, she is the cause of the outbreak, and if this was an ordinary movie about ordinary sin her backstory would be enough, it says, "this is a story about individual guilt." Oh, look: her lover was the very first person to die in Chicago.

But it's a "subtle" political piece like the kinds played on TV all day on 9/11/2011, in which the Towers fell not because terrorists flew planes into them but because of America's incessant meddling in the Middle East; the same meddling which, educated people all know, had nothing to do with the Arab Spring at all. So this is a story about collective guilt, about how we are all responsible.

If that's the story we're going to see, her sins have to be made general enough and collective enough to justify a global catastrophe. Hence, though she's blonde and an unrepentant adulteress, she's also an executive for a multinational mining company that destroys the rainforests. Now it makes sense why 2M people had to die.

Closing the narrative loop, the last scene is the big reveal, how it all happened: we see Gwyneth's company destroy a rainforest displacing a bat which infects a pig which gets cooked at the casino Gwyneth is in, infecting her. Justice is served, madame. Chef recommends.

II.

The ordinary way to read contagion/natural disaster movies is as an ===== ====== ===== The Last Psychiatrist: Cookie Monster Becomes Aware

An article from McSweeney's (I know, I know) called, Cookie Monster Searches Deep Within Himself, And Asks: Is Me Really Monster?

While humorous though predictable, I did catch a reply on Metafilter which, in my opinion, borders on genius:

They are all monsters, that's the point. The show is for children, don't forget. They are monsters the kids don't have to fear. The show's message for kids was "We know you're sometimes afraid of monsters, but not all monsters are bad.

Sometimes monsters can be cute and cuddly and quirky and funny. Elmo's a monster and he has such a cute giggle!. These are the good monsters.

Not like the monster sitting next to you on the sofa, watching the TV. Not like the monster WHO TOLD YOU FOR THE LAST TIME TO STOP CRYING.

Not like the monsters who kick your toys and curse under their breath. Not like the monsters who say you stole their youth and take pills because YOU'RE DRIVING ME CRAZY. Not like the monsters who meet strange men at the door and leave you home alone. Not like the monsters who hit with their hands, or their words. Not like the monsters who come into your room at night stinking of whiskey and sweat, with madness in their eyes and a belt in their hands.

On Sesame Street, the monsters have not HAD ENOUGH, and they aren't doing it FOR YOUR OWN GOOD.

Your monsters are not brought to you by the number 4 or the letter M. Your monsters don't want you to come and play, they want you to LEAVE THEM ALONE.

Cookie monster is safe, and so are Elmo and the Count. Even Oscar and Bert are your friends even if they are bit grouchy or fussy. Your monsters think our monsters are harmless.

To them.

Your monsters bought you a Tickle-Me Elmo doll, didn't they? They bought it to JUST SHUT YOU UP ALREADY. So they let you play with Elmo and make him laugh and giggle. But Elmo doesn't just laugh and giggle. Elmo loves you, and he listens.

And he records.

And soon, Elmo is going to tell you exactly what to do.

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===== ====== ===== The Last Psychiatrist: Couple Reveals Child's Gender Five Years Too Late

oh boy

A story that defies understanding until you realize... how old the parents are.

It's a boy! And he's five. Beck Laxton, 46, and partner Kieran Cooper, 44, have spent half the decade concealing the gender of their son, Sasha. "I wanted to avoid all that stereotyping," Laxton said.

I'm confused. Is being stereotyped as a boy worse than being stereotyped as a court jester with an extra chromosome?   "Wha--! That is so offensive!" Agreed. So why did she do it?

"Stereotypes seem fundamentally stupid. Why would you want to slot people into boxes?"

On a hunch I checked out her blog to see how opposed she was to slotting people into boxes:

===== ====== ===== The Last Psychiatrist: Craig Ferguson, The Jonas Brothers, and Katy Perry

This is what 46 year old Scottish late night TV host Craig Ferguson said Tuesday night:

The Jonas Brothers... I'm sure they're fine young kids, and their music's not for me, it's for young people, I understand that, but my point is-- they're kind of too clean. With the purity rings, symbolizing that you're saving yourself for marriage. Now, I'm thinking-- what kind of a rock star is this? What kind of a rock star is this?...

It makes me a little uncomfortable, it's a little sinister to me, when the teenage rebellion is controlled and sanitized by a big corporation. There has to be some rebellion, or else it's not rock and roll.

Ferguson was in a Scottish punk band, was a drug addict, almost suicided and is now clean-- and strong enough to make nightly jokes about using drugs and still not relapse. Rock and roll cred established.

What's he saying? He defines rock and roll as rebellion; now, and now laments is a genre.

You might say that actually, the Jonas Brothers are rebellion because they are rebelling against the established credo of rock and roll (sex, drugs, etc), but that's a ruse as well, they aren't the ones rebelling; they were selected by an industry that is trying to change it's image.

To illustrate this, take a look at the other promise ring wearer, Katy Perry, whose song, "I Kissed A Girl" has disturbed me for a long time, disturbed me because it is so not disturbing.

In case you don't have kids or contracted rubella as a fetus, here's the chorus:

I kissed the girl and I liked it
The taste of her cherry chapstick
I kissed a girl just to try it
Hope my boyfriend don't mind it
It felt so wrong
It felt so right
Don't mean I'm in love tonight
I kissed a girl and I liked it
I liked it

That's as raunchy as it gets. Anyone who lived through the bicurious 90s knows that this kind of "kissing the girl" is about boys. It's about being sexy for boys, even if the boy doesn't know you did it, you still feel you are even more attractive to them. But this is by no means cutting edge material.

I will grant you that the song is technically, and artistically, more brilliant than anything by Coldplay. Ok, you got me there.

Yet the song is everywhere, not just pop song everywhere, but everywhere everywhere. Here are three news media outlets that have no business writing about music, writing about her. And always the topic is sexuality, as if she's opening (or closing) doors or something.

I had a huge argument with a friend about that song. My position was that such a benign song-- this is old news-- has a popularity that cannot be explained by the seemingly relevant topic of kissing a girl, there must be something else to it. Why would the music industry choose to push this specific song, so much?

His position was that it was MTV et al, targeting the older people, the ex-MTV generation-- e.g. me-- trying to entice them back with songs that play on their (unfulfilled) fantasies. "Why else would they be in lingerie? Young guys don't care about lingerie, unless it's a thong. They're programming to the older crowd."

Maybe, but why this song? Why not a million other more risque songs?

So here is this not at all provocative video, completely old news to anyone 21-45, yet it is everywhere. Go ahead and watch it, tell me why. No nudity. She's pretty, but come on, she's no Taylor Swift. Song is catchy, but again...

I call your attention to the last five seconds of the video. In the final scene, she wakes up next to her sleeping boyfriend. Ooohh-- is he going to find out how naughty she is? Will he be jealous or turned on? Is it fantasy or real?

Here's the thing. Her boyfriend in the video is black.

If that realization doesn't have any impact on you at all, you are my point.   You may be so progressive that you don't even notice race, but I can assure you race is still a gigantic issue, for both races.

We have a scenario where two maybe-sort-of taboos are present in a video, but one is highlighted as a real taboo, and the other as completely and utterly ordinary, meriting no comment or explanation. I'm pretty sure depending where you live in America, you'll either agree or disagree with her hierarchy.

In all the Katy Perry discussions, blogs, and articles, no one noticed the race issue, no one thought to mention it, nothing. What they went all Manchurian Candidate about was that she kissed a girl.

"Well, maybe that's what she believes." She doesn't have anything to do with it. She didn't make a video, then go Jet Li the MTV program director's office door, slap him in the face with the reel, and say, "This is f-ing awesome, play this!" "oh-oh-oh right away Mrs. Perry! Right away!"

The video was directed, manufactured. The guy in her bed isn't random, they selected an actor. It wasn't accidental he was black, they picked him because he was black. Indeed, he's DJ Skeet Skeet, a friend of her real life black rapper/boyfriend Travis McCoy. Nothing here is random; even her name, Katy Perry, was selected because her real name, Katy Hudson, risked confusing her with Kate Hudson. She changed her name to differentiate herself from someone else. They are constructing an image, they are telling you a story.

So what's happening here is that MTV isn't saying, "wow, this is so shockingly sexy, she kissed a girl." MTV is actually resetting the culture, it is telling you, telling a generation of kids, that kissing a girl is shocking and sexy.

"But it isn't shocking, you can't simply declare that it is. Much more shocking porn is everywhere." Actually, that's the genius of this. Reconstruct adolescent sexuality to the old days of maybe you catch a glimpse of a worn and melted Playboy down by the creek. Online porn saturates, overloads, it stops becoming arousing and starts getting frustrating, "where the hell is the exact pic I need to get off?"

MTV can't compete with that. Music can't compete with that. In your face, up yours, all that. Those vibes are now elsewhere.

So it's recreating a niche by recreating a culture. Clean, sober, and hip-hop light.

So that when you turn the amp up just a little, it catches everyone's attention. "Holy crap! She kissed a girl!"

I'm not sure if I should be appalled that sexuality has been commandeered by MTV et al, or I should just be relieved they're pushing popcorn not penetration.

Back to the Craig Ferguson. The music industry has to make good boys cool because there's a glut of bad boys everywhere else, and MTV and the music industry can't compete. Sex is no longer cool. What's cool now? Status. Narcissism. Rich is the new porn.

But poor Craig Ferguson. He makes the point that rock and roll is supposed to be about rebellion-- theoretically getting a big inaudible cheer from the teenagers-- "this guy may be old, but at least he gets it!" But he doesn't. That cheer came from his viewers-- who have an average age of 50. He's talking to a bunch of old guys, people who still think Smoke on The Water meant something.

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===== ====== ===== The Last Psychiatrist: Crazy

it works not because everyone is different, but because we're not

Crazy: Notes On and Off the Couch is a new book by Rob Dobrenski, a PhD psychologist in clinical practice. He emailed me and asked me if I would review it. Note to everyone else: this is a terrible idea.
The book is about his experiences as a therapist, from the difficulties with fees to working with sex offenders.
It's a memoir, but once you publish a book readers interact with it in their own ways, pulling into it things the author hadn't even considered. It stops being non-fiction and becomes a story.
So instead of reading it like a memoir, let's read it like a story, and see if we can't learn something about ourselves.

II.

Dobrenski's book is about his work with clients, but it's about two other things.
The second thing it is about is his own therapy with a therapist. It's a parallel story, as he's helping people work through their issues, he's working through his own.

But this is a narrative, and every narrative has a first thing-- an inciting event. Robert McKee's Story defines the inciting event as "an event that radically upsets the balance of forces in the protagonist's life." It's the event that propels the story, without which there is no story. Rob Dobrenski complies with McKee's directive to "put the inciting event into the story as soon as possible"-- he puts it in the prologue. It is this: he meets Janet, a beautiful redhead in his training program, his soulmate, "the one."
And she dumps him.
Now you have a story.

III.

From McKee's textbook of psychoanalysis:
Story begins when an event, either by human decision or accident in the universe, radically upsets the balance of forces in the protagonist's life, arousing in that character the need to restore the balance of life. To do so, that character will conceive of an "Object of Desire," that which they [believe] they need to put life back into balance. They will then go off into their world, into themselves, in the various dimensions of their existence, seeking that Object of Desire, trying to restore the balance of life, and they will struggle against forces of antagonism that will come from their own inner natures as human beings, their relationships with other human beings, their personal and/or social life, and the physical environment itself. They may or may not achieve that Object of Desire; they may or may not finally be able to restore their life to a satisfying balance. That, in the simplest possible way, defines the elements of story.
Everything that happens in your life is digested by you through this process, so it would be worth your time to memorize it.
IV.
So we have a story about a man who loses his soulmate and becomes miserable, Zoloft and therapy miserable, passive suicidality and eating her photograph miserable, all while becoming a therapist and struggling to help others.

I'll grant you that he's 25 when Janet comes and goes, so some confusion, soul searching and drama is to be expected. The issue for us therefore isn't whether his reactions are normal, but why they are not uncommon. Why do a lot of men go through this, in this way?
How does a therapist do therapy, which is a kind of story? How does a writer do a story about therapy, a story about a story?
Step 1-- actually, there's only ever one step-- focus precisely on the words.

Here's how he describes Janet:
never before (or since) had I ever believed in the notion of Love at first sight... it was as if the film Weird Science had come to life and someone had created this physical specimen just for me. Or maybe the gods had simply decreed that this was the moment I was to meet my soul mate. Something clicked, and I made a conscious decision to form an indelible bond with her.

Remember: this is in the prologue. This is what starts the story. Of course it's a book and of course it's written after the fact, and hell, perhaps it isn't even true but none of those things are relevant because psychology operates outside of time and space. "Well, that part's not true, I made it up." How can you understand what's true, Dusty? Truth has seven levels. Instead, just focus on the words.
Which words? Note the words, "conscious decision." That's not a throwaway phrase. If it was his soulmate, if the gods had decreed it, it wouldn't be a decision any more than you'd say it would be a decision to win the lottery or fall into a hyena pit. But that he chose to fall for her, decided that he knew how special she really was, decided to fall into a hyena pit-- then you no longer have a story about unrequited love, you have a story about old school Freudian masochism. Think about this.
As a small point, he didn't realize it, but at that moment he was exhibiting a form of "ownership bias" quite common among 25 year olds: since he was able to get this hot girl and others didn't, this must be a special relationship indeed. If you consider that the purpose of this ownership bias is the reduction of cognitive dissonance, then what it defends against is buyer's remorse.

But the point for us here is that even before we leave the prologue of this story or finish the first session of therapy, we should already understand that in order for him to get over her, to "restore balance in his life," he's going to have to figure out why he did this to himself.

V.

The other thing of note in that paragraph is the movie choice, Weird Science. Here's a handy life tip: when someone likens their life to a book or movie, pay attention, that's more informative than two MRIs and an Amytal interview. Second tip: when they do reference the movie, the important thing about it is the thing they forgot. So what do we know about Weird Science?

We know it was made in 1985, which means Dobrenski's sexuality began to form around the narratives and images of that time, which is why he referenced this move and not Bride Of Frankenstein or Simone. This is important because when you're trying to understand someone's relationship to sex, you have know the stories the person uses to value it, i.e. the stories they were immersed in during their teens. In the 80s, that meant getting not the hottest girl, but the girl from the higher class.(1) It also divided society along a two party system, preppies vs. nerds, "beautiful people" vs. "untouchables."(2)

His use of Weird Science was intended to mean, "a perfectly constructed woman to my exact physical specifications" but that's not what it means. Three paragraphs later, describing his surprise at her dumping him, he says this:

I was so dumb that I was actually shocked when it happened. But we were meant to be together! Didn't you see Weird Science?!
I saw Weird Science, all the way to the end, the end where the boys decide they don't want their perfect woman and make her leave (in this case nicely.) I'm sure Janet thinks she left and I'm sure Rob thinks she dumped him but I'm all in that he did everything in his power to make her realize he wasn't right for her, to make her do the hard work of leaving him since he couldn't cut that cord himself. When you have your perfect woman for the 90 minutes of a movie and you never have sex with her, I suppose it could mean you're just nervous but it probably means she's not your perfect woman. (I'll grant that the opposite is not at all informative.) And Rob may have had sex with Janet, but he probably doesn't have to think hard to find a million other examples of things he did that, in retrospect, clearly told him Janet wasn't the One. It's hard to depict psychic resistance in a visual story; in dreams it is done by feeling stuck or slowed, but one solid way to do it in a movie is by making the character wear pants in a shower while Kelly LeBrock is naked. So Weird Science isn't about getting the perfect woman, it's about realizing you don't want the perfect woman.

Once she gets dressed, Lisa and Janet's entire purpose is to build up their self-confidence; create some scenarios where they can manifest their identities, and then get out of the way.

The point, however, isn't that Dobrenski's movie choice was wrong, or that he misunderstood its story. The point is that he chose perfectly, but misunderstood why; which is why in therapy and in stories, similes aren't accidents. "Lisa is everything I ever wanted in a girl, before I knew what I wanted." I hear you, Rob.

VI.

But I'm jumping ahead. Let's get back to the story.

Rob is miserable when she dumps him. Janet was perfect, and Janet is gone, into the arms of a different man. And another man. And another one. And guess what? All the men are hot. And so is she. And etc.

Or so he imagines. Carol, his therapist, tries to clear him by asking him to describe these images that plague him, of Janet and her other lovers. So he says,

Janet is in her bedroom... She's gorgeous; she's wearing a negligee that she bought when we were together. She's smiling and being all seductive." [And the guy?] "He's tall, like six-foot-two, a little bigger than me. He's good looking. Very good-looking, built and strong.

Carol correctly interprets this all as a self-defeating negatism; he creates a "flawless rival" in his head that he can never best; which virtually guarantees his ongoing misery. Only when he understands that this image is unrealistic will he get over her. So, she suggests, try to take these fantasies to their conclusion. What happens after they have sex? Does the guy leave? Is she hurt that she was used? Does she go to the bathroom? Etc. Make her a real person, and not a porno.

In this way Rob slowly gains control of these images and fantasies. "When images become boring," says Carol, "they go away. And, fortunately, so do your symptoms."

So it helps Rob, but it leaves an unanswered question: why did he have these images in the first place?

VII.

In "The Ghost of Janet" he describes the sessions that deal with getting over Janet and his "irrational cognitions," e.g.
She was perfect.
I'll never meet anyone else.
I'm a worthless person and I don't deserve anyone.
I'm nothing without her.
The typical way of working these problems is to realize that they aren't true, that they are self-defeating; that they originate in childhood, that they are the results of insufficient, or inconsistent, parental love. That's the typical way, and the wrong way.
Tell me about Janet, his therapist asks. What did you like about her?
He describes what he liked about her in detail. We're in a story, so focus on the words:

She was fun to be with.

"I miss being sexual with her." "I felt good with her."

She was good looking, but in italics he writes, All these guys want to be me.

I hope it is immediately obvious, through this simple exercise of saying in words what you think can't be expressed in words, what's wrong with his love for Janet: none of those things have anything to do with Janet. They are all about him. In fact, Janet is pretty much an inanimate object, a MacGuffin. The therapist detected it as well: "Could she be more symbolic than real in some ways?" Cross out the last three words and you have it.

This applies just as readily to the guy who is upset/sad/angry that he can't get a beautiful woman, not stopping to know or care if they should get together. She isn't real, she's just a plot device to move your story along.
Hold on: it is IMPOSSIBLE to understand you are doing this while you're in it, while there is a real life woman in front of you, "it can't be all about me, look, she smiles when I buy her roses!" Which is why doing this exercise is so important.
"But I'm not insecure!" you might say, "I just like hot chicks!" No doubt. Which is why Dobrenski's summation is perfectly accurate: "I don't believe I need her to feel good about myself. It was just easier to feel good about myself when I was with her." Nothing like an accessory to reinforce a brand.

VIII.

Note also that this is definitionally narcissism, but it's not at all abnormal-- this is a totally ordinary, mid twenties kind of narcissism. It is not pathological. But that doesn't mean it doesn't hurt just the same.

IX.
Back to the upsetting fantasies of Janet with other men. We know he got over them by imagining more realistic scenarios. The question is, why did he imagine the unrealistic ones?
"Lots of times I paint a picture that she's a raging slut who's screwing a new guy every other night," [he says to Carol, his therapist.] "Other times it is her soul mate. Both drive me crazy."

At that point Carol decided to teach me an interesting trick.

"We've talked a lot about how our thoughts influence our mood. People make the assumption, however, that we always think in words. Here is a great example of how your cognitions are actually pictures. The images are your thoughts, which are driving this jealous reaction. The good news about this is that images are just like a film, except you are the director. With a little practice you can make the camera do whatever you want. Please, take me through one of these images."

And he describes the scenario of seductive Janet in her negligee and the built 6'2" guy about to plow her.
The trick is that Carol's trick isn't a trick, it is the entire purpose of the fantasies. Carol is going to help Rob make the camera do whatever he wants, as if the camera was right now doing something he didn't want, but in fact the camera is already doing exactly what he wants. The camera isn't making him miserable, it is keeping him from going insane.
If we're in a story, and Rob is, than these fantasies are exposition, they are telling the audience something.   Look closely at these fantasies, at your own cuckold fantasies. Inevitably in these fantasies there is a fetish object, something that existed in your relationship. It's seems incidental to the fantasy but it is highly energized, eroticized: a piece of jewelry, clothing/bathing suit, or a location (car, bar, beach, etc). The sex is the visual focus, but the eroticized negligee that they bought when they were together is the true main character of the fantasy.
Men make the sex the focus, while women make the fetishized object more explicit: they obsess over the ex taking his new woman to the same places; or buying her "the same kind of scarf he got me"; or saying the same phrases ("that's what he used to call me.")
It seems masochistic, driving yourself crazy thinking about what you've lost, making the loss even worse by finding the specific ways that it hurts you.
But look back at what Janet was to Rob. What he really liked about Janet was what <<Janet>> meant about him. In Jerry McGuire, when Renee says to Tom, "you had me at hello," it's in response to the mushiest yet most accurate line in the movie: "you complete me." No kidding. So when Janet leaves, he doesn't lose her, he loses what the part of him she completed. That's what hurts him. The fantasies are a battlefield medic sewing up a wound of the self with dirty thread and a rusty needle. But at least you're alive.
Sure, on the one hand you've had a huge piece of your identity torn out-- you wanted to be the kind of guy who dated the kind of girl that Janet represented, and by leaving she's shamed you, exposed you as not that kind of guy, as a loser-- but on the other hand you were that guy, and you can prove it: she's wearing your negligee.
That loss of self is what you're trying to recapture with the masochistic fantasies: she's hot enough to have any guy she wants (and she picked you); she is in total control of her sex, wielding it for pleasure or for profit however she wants; so when she had sex with you, and liked it-- it signifies your own value. When some faceless stud undoes her bikini top in front of everyone, and she confidently flaunts her body-- that's your self-confidence she's flaunting.(3)
Since you see the fantasies but not the wounded self you think one's real and the other isn't. The hard part is to accept these fantasies as merely information, as part of the story, what do they tell the audience? The fantasies aren't the wound, the wound you have to close is the self: I'm not broken now that she's gone, I'm not a worse person, her leaving doesn't reveal me to be a loser. The next woman I meet will not know or care that I am the man Janet dumped. I'm depressed but still whole. I want her to have sex and be happy, or frankly it doesn't matter if she has sex, because it has nothing to do with me.
When that wound closes, you won't need the fantasies anymore. Or the negligee.

X.

Rob closes his book with parallel stories of endings: ending of his therapy, endings of clients' therapies, and endings of his involvement with clients' ongoing therapies. Actual therapists spend offensively little time understanding how and when to end a therapy (Rob and Carol do it right); and even ordinary humans seem to have great difficulty, anxiety, saying good-bye, hanging up the phone, not feeling compelled to tack on a "why don't you text me when you've settled in your new place?"

But knowing how to end things, whether it is therapy or a relationship or a book, is a fundamental skill that allows us to move on. Otherwise the past is dragged around like a deployed parachute, slowing your every move and suggesting to anyone who sees you that you must only just have landed.

Every story has an ending, and the more satisfying the ending the better the story.

------------

1. An example: Molly Ringwald played the unpopular kid in Sixteen Candles, pursuing the preppie jock; yet in The Breakfast Club she played the popular, "beautiful" type pursued by marginal character Judd Nelson. She looked exactly the same in both, but her "value" as sex object (not girlfriend) was higher in The Breakfast Club. She went back to being a desexualized person (not object) in Pretty In Pink. John Cryer, who was in love with Molly throughout the movie and eventually loses her to the preppie guy, is compensated for his loss by the sex object Kristy Swanson.

2. Movies like Heathers and ultimately Mean Girls permanently disposed of this narrative, and high school movies now generally favor parliamentary style politics: multiple parties forming coalitions. Teen movies now also downplay the ages, so while the plot of Weird Science couldn't be redone using 40 year olds, you could flip the ages in The Hangover or High School Musical and the stories and their themes stay mostly the same. They are both movies about childish adults, or adultish children, which are the same thing. Interestingly, Zac Efron's other movie 17 Again believably recreated 80s style power divisions and objectifications precisely because it was a movie about a middle aged man being 17 again, i.e. the movie was believably the worldview of such a middle aged man.

3. There is an element of aggression in these fantasies, and the extent to which this or the other explanation is operational depends on how "whole" you were to begin with. Unconsciously and deliberately putting your ex in these fantasies, forcing her to have sex with strangers, forcing her into sex she would not want herself; commandeering her image without her consent, destroys the integrity of the woman by reducing her only to an object-- all of these are regressive acts. This is a kind of revenge, compensation for the loss-- if I can't have your love, fuck you. (see footnote 1, above.)

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===== ====== ===== The Last Psychiatrist: Cut Rates Now

I'm putting myself on the record (not that I haven't a dozen other times on this site):

there is no inflation, if there it is two, maybe three years out at the earliest. This is massive deflation before your eyes, not even including the outstanding credit card balances and other personal loans which will never get paid, especially when the jobs start evaporating. No money=no buying, no buying= companies cut back, companies cut back=job cuts...

Add to that the pressure for the government to come up with (emergency) healthcare and other public assistance and the situation becomes untenable.

Oh, and Al Qaeda. That's right, I said it.

There are two solutions, and in order for them to work you have to do them today.

1. Cut rates.   Dollar is stronger, oil is down, we can take it. Worry about inflation later. Worry about the never-going-to-happen wage inflation later. This is better than bailouts, which will lead to inflation.

2. Cancel mark to market: there is no market. You have ancient Chinese vase woth millions, but because the economy's bad no one wants it right this second, so on ebay it's still only at $2. Is it really worth $2? Should the bank get to repossess it when you go under for $2? That's where we are now. You're calling them 20% when they could be 60%. (The government may actually make money on FNM and FRE if/when this passes.) The result is you might actually be worth something, but still evaporate.

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===== ====== ===== The Last Psychiatrist: Who Bullies The Bullies?

but they're welcome to buy an iphone

Pacific Standard. Get it? It's like The Atlantic, but it's Pacific. Totally different. So unlike The Atlantic, it will "attack the conventional wisdom from a west coast perspective." That's a quote. "But didn't the editors come from The Atlantic?" Yes. "So what's the diff? Does west coast imply the writers will be better looking?" The women will be, unless they write about gender issues, then they will appear gendered. The men will look wise if they're crushing on social science, or tough and no-nonsense if they're hating on Republicans. Don't worry, pics of the writers will be included to suggest an appeal to authority. "Hold on, is the owner of this magazine Sara Miller McCune? The same woman who is responsible for those atrocious SAGE journals like Psychological Science and Evolutionary Perspectives On Human Development that charge CV padding post-docs a few hundred dollars to publish linkbait like "Ovulating Women Prefer Men With Large Sneakers", that Malcolm Gladwell and media outlets like Pacific Standard then cross promote as valid science?" Yes, but I'm sure it's a coincidence. "This magazine sounds terrible." Duh.

This cover story details #young #vulnerable #feminist writer Amanda Hess's frustration with disinterested male law enforcement when, after writing an article about receiving rape threats from a troll, she received rape threats from a troll. I sympathize, though in my experience what's even more frightening than a guy telling you he's going to rape you is a guy not telling you he's going to rape you.

There's a big push for "women's safety" online, for getting rid of trolls and cyberbullies and cyberstalkers, not coincidentally another one of Randi Zuckerberg's pet causes; and while these are all legitimate worries someone should take a minute and ask why, when mustached men have been stalking women since the days of Whitecastle yet no systemic changes have been effected, the moment women feel threatened from the safety of their LCD screens America opens the nuclear briefcase. No one finds that suspicious?

In fact, regular stalking is barely ever mentioned in media, no matter how many times the guy was laying under her new boyfriend's front porch on Wednesday nights after Organic Chemistry class, what drives the article is "and then he stalked her on Facebook!"

Here's just a sampling of the noxious online commentary directed at other women in recent years. To Alyssa Royse, a sex and relationships blogger, for saying that she hated The Dark Knight: "you are clearly retarded, i hope someone shoots then rapes you." To Kathy Sierra, a technology writer, for blogging about software, coding, and design: "i hope someone slits your throat and cums down your gob." To Lindy West, a writer at the women's website Jezebel, for critiquing a comedian's rape joke: "I just want to rape her with a traffic cone." To Rebecca Watson, an atheist commentator, for blogging about sexism in the skeptic community: "If I lived in Boston I'd put a bullet in your brain." To Catherine Mayer, a journalist at Time magazine, for no particular reason: "A BOMB HAS BEEN PLACED OUTSIDE YOUR HOME. IT WILL GO OFF AT EXACTLY 10:47 PM ON A TIMER AND TRIGGER DESTROYING EVERYTHING."

As the recipient of not zero decapitation emails I admit it does make you curious about whether or not you can buy an alligator, but while you're arming your windows like a Saw movie you should contemplate the difference between what should be done and why it appears something should be done.

I.

The force for this change isn't coming from safety or ethics. Neither is it activism. If you see any group advocating influentially for change in a media they don't own or control, you can double down and split the 10s, the dealer is holding status and quo. No change is possible on someone else's dime, and if what looks like a supermodel approaches you with a microphone and a camera crew, you should run like she's Johnny Carcosa. On occasion what the activists think they want may happen coincidentally to align with what the system wants, and from that moment on they will be lead to believe they are making a difference, which means they're making money for someone else. "Your writing is so muddled." Sorry. Were you better persuaded by the concise prose of Amanda Hess?

Her article seems to be about what could be done to stop anonymous trolls from terrorizing and threatening women. How about prosecuting them, since terroristic threats is already a crime? Unfortunately, as Hess discovers, the police don't care much about online stalking, which is consistent since they don't care about IRL stalking either. But never mind, it's not the problem: misogyny is the problem, amplified 1000x by online anonymity. Anonymity makes the internet mean and gives trolls= men too much power. This is the subtle shift: what starts out as "misogyny is bad" becomes "anonymity facilitates misogyny."

Keeping in mind that actual stalking has never been dealt with in any significant way ever, the desire of a few female writers to curb online anonymity wouldn't be enough to get an @ mention, except that this happens to coincide with what the media wants, and now we have the two vectors summing to form a public health crisis. "Cyberbullying is a huge problem!" Yes, but not because it is hurtful, HA! no one cares about your feelings-- but because criticism makes women want to be more private-- and the privacy of the women is bad. The women have to be online, they do most of the clicking and receive most of the clicks. Anonymous cyberbullying is a barrier to increasing consumption, it's gotta go.

II.

You may at this point roll your eyes epileptically and retort, "well, who cares 'what the system wants', the fact is anonymity does embolden the lunatics, shouldn't we try to restrict it?" Great question, too bad it's irrelevant. You've taken the bait and put all your energy into accepting the form of the argument. The issue isn't whether we should abolish online anonymity, since this will never happen. For every American senator trying to curb anonymity there's going to be a Scandinavian cyberpirate who will come up with a workaround, and only one of them knows how to code. Besides, there's no power in abolishing anonymity, the power is in giving everyone the pretense of anonymity while secretly retaining the PGP keys to the kingdom.

To understand what's really happening, start from basics: if you're reading it, it's for you. I assume you're not a cyberbully or a stalker. So do you have any power to abolish anonymity?

If Hess has made you wonder, hmm, maybe unrestricted anonymity is bad because it gives trolls too much power, then the system has successfully used her for its true purpose: brand it as bad, to you. She is unwittingly teaching the demo of this article, e.g. women in their 20s with no actual power looking to establish themselves, who are the very people who should embrace anonymity, not to want this: only rapists and too-weak-to-try rapists want to be anonymous. Smart women write clickable articles about their sexuality for nothing, because what good are you if you can't make someone else money? Interesting to observe that the article's single suggested solution to cyberharassment is to reframe a criminal problem into a civil rights issue using a logic so preposterously adolescent that if you laid this on your Dad when you were 16 he'd backhand slap you right out of the glee club: "it discourages women from writing and earning a living online." Earning a living? From who, Gawker? Most of the women writing on the internet are writing for someone else who pays them next to nothing. None of them control the capital, none of them get paid 1/1000 of what they bring in for the media company. You know what they do get? They get to be valued by work, and in gratitude they are going to the front lines to fight for the media company's right to pay them less.

And the indoctrination has worked, the less Asperger's a woman is, the more she'll hate writing anonymously. Don't get angry at me, they did a study, and I think it explains why women don't want to write for The Economist. In the reverse, put a pic in your byline and you improve your female audience; put a pic of a female in your byline and you've maximized ROI, everyone will click on a pic of a chick. This is economic and psychologic universe in which Hess finds herself.

"But you can't use a pen name at places like The New Yorker. You know they pay their top staff writers $100k a year?" Jesus. a) yes you can; b) listen to me: if those swindlers are willing to pay you $100k, then you could probably get $200k yourself, and if you can't get $200k yourself then you aren't worth their $100k either and they will eventually notice. When they pay you that much they're not paying you to write for them, they're paying you not to write for anyone else, that's called controlling the capital.

"So your solution is that she should use pseudonym? Isn't that blaming the victim?" No, not her-- you. You should use a pseudonym. You aren't writing for Gawker, you just use the internet, comment on things, etc. Why should you use your real name? "Why shouldn't I?" I'm sorry, I wasn't precise: why are you being encouraged to use your real name? Again, the question of whether anonymity emboldens trolls is not the force of that article, it isn't about their behavior, it is about yours.

"But merely 'branding anonymity as bad' isn't going to stop the cyberbullying misogynists." You are correct, which is why the spokesperson for this crisis is Amanda Hess. No one is trying to stop cyberbullies, there's no point, they don't shop and no one wants to look at them. Hess has entirely misunderstood what the medium wants. The whole game is to get women-- not the cyberbullies, not criminals, but the consumers-- to voluntarily give up all of their privacy, while paying lip service to privacy at home-- knowing full well women that women will pay money not to have the kind of privacy they have at home. Voluntarily exposing yourself makes you a targetable consumer and targetable consumable. Is it worth it?

III.

All of this is for the benefit of the media, which is why I know with 100% certainty that nothing will change. Because she wrote that article, because some people camped in Zuccotti Park, the energy for activity was discharged. And the media got all the profits.

What Hess didn't realize is that while she was fumbling impotently with the cops, the media company that she worked for could have crushed the troll if it was worth it to them. Did you have this thought? If not, it's not your fault, some people are trained not to have it while others were trained to have it immediately. Which are you? If the founder of Religions For New Atheists Sara Miller McCune herself had received an electronic rape threat from some Fox News stenographer in a Kentucky man cave, you think she's dialing 911? From her apartment? She would have waited until she got to the office, waved her hands like in Minority Report and her lawyers would have midnight Seal Team Sixed him while he was overhand jacking it to interracial porn. Do you know what Hess's employers did for her? No, I'm serious do you know? It can't be nothing, right? That would be Bananastown. It was nothing? Really?

Maybe hypotheticals aren't your bag, ok, here's a true story: "Amy" received a couple of voice messages from a "customer" she met at work who wanted to put something in her vagina. These messages were not violent, in so far as forcing your fantasies of consensual sex into an unwilling girl's ear is considered not violent, but of course they creeped her out. There's one other crucial piece of information needed to understand this story: her harasser probably had large sneakers. I'll give you all a minute to catch up.

Every woman has some version of this story, with one important difference: Amy was a medical student, which meant a lot of money went into her and a lot of money was expected of her. One (1) phone call from the Dean to a phone number that was not 911 and that guy was evaporated. Two cops located him minding his own business, and because he defended himself with the magic words-- and you should write these down, they're gold-- "it's a public street, I have a right to be here"-- he was jailed for eight months for harassment and resisting arrest-- pre-trial. Pre means without. Of course his case was ultimately dismissed. Does that matter? Please observe a) Amy herself didn't have to do anything to effect any of this, she was mostly unaware of the results, the system was on autopilot; b) he was jailed not for what he did but for whom he did it to, had Amy been a 1040EZ at the Footlocker we'd say she was asking for it. "But it isn't fair that her protection money should get her concierge policing while the rest of us have to make due with socialized law enforcement." Was it fair that he did eight months because he couldn't afford bail, is it fair that he didn't know that it wasn't fair? On the other hand, was he a dangerous nut, should he have been punished? Of course. Was he operating from a perspective of institutionalized sexism, patriarchal thinking, misogyny? Sure, #whatevs. Sometimes the structural imbalances go your way, and sometimes they don't, better figure out who makes the scales.

After Hess got the runaround, she spent a lot of time trying to get a protection order, a force slightly less compelling than wind. Why didn't she just call the Mayor? "Hi. I work for the city paper, the one that caters to voting Democrats and men looking for Russian companionship. I'm doing a story about police apathy regarding sexual violence from a first person perspective, by which I mean your perspective. Comment?" That would have solved her problem, but more importantly it would have forced her to think about WHY that solved her problem. What is the difference between a "woman" who is threatened and a "reporter" or "medical student" who is threatened? Why is it more bad to attack a journalist than a woman? Think about that, it has not always been so. The former is an attack on the system, so the system must respond; the latter is an attack on a woman, so -------------------------------------. And so it goes.

But Hess preferred to see misogyny on the internet, so instead we get another trending article about how the problem has a penis. This coincides perfectly with the media's desire to frame it as a gender war because that makes for good clicking. Let's summarize the media's thesis via unwitting Hess: 1. cyberharassment is a women's issue, never mind the men who are harassed. 2. The appropriate way to handle women's issues is not necessarily to solve them but to discuss them in the media. "It's called awareness." We are all aware. Are you aware of how much you made for Pacific Standard at your expense and to no avail?

IV.

Hess is fighting the battles of 50 years ago because she was told to fight them by people who profit from the fight, and as a bonus it gets her out of any self-criticism. Oh, Sheryl Sandberg thinks Silicon Valley can be a boys' club? Was that why she manned up and sold us out to the NSA? Curious that she didn't accuse the NSA of being a boys' club. Perhaps real power transcends gender? More curious/on purpose is that she and the boosters at Wired are more horrified about NSA spying, despite there being an explicit terms of service agreement with them that what it finds without a warrant is inadmissible, but Google monitoring my sexts for their commercial benefit is SAGE approved behavioral economics. Google buying Boston Dynamics is better than DARPA having it, is that the game we're playing now? If I had to put my chips and my children against an 8 year rotation of civil service nincompoops vs. some nerd with an open marriage who spent $15M on a "bachelor pad" so he could score chicks of questionable emotional stability, I'm going with the group my private sector lawyers have an outside chance of pwoning. "But how cool is that guy that he could spend $15M on scoring chicks!" You're looking at it backwards, the only way he could score chicks was by spending $15M, and now that guy owns cybernauts. Power corrupts, but absolute power doesn't exist, so for everything else, there's Mastercard.

What Hess and others fail to see is that this kind of postgraduate sexismology-- Hess's "ability" to see it-- is encouraged because it favors the status quo. It is a tool for maintaining an economic and psychological disavowal favorable to Gen X and older-- men and women. Their collective psychology has caused to be a machine that is calibrated to ensure their life is not disrupted-- at the expense of everyone under 30, you guys waste your life Banning Bossy and make sure you pay back all of your student loans, sorry about the future but the SLEEP/CONSUME machine from They Live has to keep running.

Here's a "class struggle" example: name one Wall Street type who went to jail post 2008, everyone picks Bernie Madoff. Now name one person you know who was harmed by Bernie Madoff. That's weird. Note he didn't cause the crash, his criminal empire was a "victim" of the crash. What got him jailed was stealing from the wrong people-- that the media coded as either "celebrities" or "pension funds". Look carefully at the result: you got a distraction to label as evil so you don't have to feel any guilt about overusing your credit card; the rich guys get (some of) their money back; and the media makes millions of dollars engaging you in a "conversation." "But he was symptomatic of Wall Street excesses." Way to treat the symptoms. Hence the most important result: nothing changed. The whole thing is a defense against change, for the system and for you. Still have that credit card at max?

Radical political action, radical as in "outside the frame" radical, the kind self-aggrandizing #OWS is incapable of, would be to demand Bernie Madoff be released, so that everyone would have to watch him in restaurants and hookers, an unignorable signal to the system and to yourself that things are not right. Not to settle for symbolism and scapegoats. But the media won't let this happen, they thrive on symbolism and scapegoats; and you won't let it happen as long as you can get an iphone.

So the system encourages women like Hess to "critique the patriarchy" or "bring awareness" because it stands no chance of moving the money, let alone the power, and also the media gets a cut. Meanwhile men all over the place are left questioning why their opportunities are just as limited but their answer can't be a glass ceiling. "Maybe it's reverse sexism!" Maybe your media is no different than her media, we'll see what kind of sexism there is when the robots replace all of you. What is both obscene and astonishing in its power is that this distraction is foisted on Millennials by other Millennials, they're fighting for the other team, precisely because the immensely hard work of work can be avoided by hoping the problem is sexism. Hess is frantically fighting against-- whom? Cyberbullies? Frat guys? Stand up comedians? What are the results she expects from this fight? The fight is a symptom of neurosis, frantic energy as a defense against impotence, frantic energy as a defense against change. "Why am I in the top 20% of intelligence but I'm running the register at a store whose products I can't afford?" Because trolls are preventing women from earning a living online? "So it's Reddit's fault!"

V.

There should be no controversy: a guy should never tell a girl he's going to rape her, online or not, kidding or not. I get that he's probably not serious, but there should be no instinct at all to defend such a jerk, and yet----- and yet that is precisely the instinct many people get. Men who have never wanted to threaten anyone read Hess's story and side with the troll. And Hess will agree: it is a massive number of people. So they're all misogynist jerks, too? No other explanation?

Yet a typical such "misogynist" probably has a wife and daughters whom he loves in a more equal way than sexists in the Whig party did. He is aware his daughter is a girl, he wants the best for her, he'd be thrilled if she became President, do you think he doesn't want her to have power/money/influence, more than any man? And of course he wouldn't want his daughter to receive such rape threats, but what's important is that he believes she wouldn't-- she wouldn't deserve them.

There is plenty of existing sexism and [insert lip service here]. I do not deny or minimize it, the point here is to identify the self-imposed kind of oppression, instead of top down it is bottom up: impotence. All of these choices, all of these products, all of that sex, all of that power-- why not me?

The troll and Hess have this feeling of impotence, which Hess easily finds to be the fault of patriarchy, which she uses interchangeably with class, except when that class is Sarah Miller McCune, then it's just patriarchy. The troll thinks the source of his impotence is "militant feminism", which also explains why he's not worrying about his daughter. She's not a woman, she's a person, i.e. like all American parents, he's raising her like a boy: school x 16, sports x 12, violin x 6, and for everything else there's LCDs. I don't know why he thinks his daughter will fare any better through the same machine that is failing his son, but I guess it's worth a shot. Of course, he probably won't be too happy if she becomes a "feminist"; e.g. living with a teenage Zosia Mamet drove David Mamet to the Republican Party. I'm going to go ahead and protect myself by saying that's a joke.

So in order to explain their otherwise irrational feeling of impotence, they pull from any of the media-approved categories of blame, depending on your news network: sexism, racism, feminism. The central importance of the media in soliciting their anger is totally lost on the older "activists" who still believe that the -ism is the primary force. They're enraged that a white Princeton student would dare to write that white privledge doesn't exist; they never wonder why they read it. They are at a loss to explain why the very same trolls who want to "rape" feminist bloggers are even more enraged that women in Saudi Arabia are forced to wear burqas. So do misogynists hate Arab men more than American women? Is there a hate hierarchy? Yet the media is unsurprisingly ambivalent about the burqa, the feminism risks an assertion of cultural priviledge so they'd just as soon not get involved. And to hell with George Bush who made us have to.

There was a time not long ago when the dumbest people in the world were polacks. Do you see any dumb polacks around today? What happened? "Awareness?" Do you think we all just learned "poles are just like us?" You think it was... education? Pole empowerment? Tolerance? The question is not how did we learn to get over that prejudice, but rather what purpose did it serve in the first place, why was it the preferred expression of hate of that time?

VI.

Hess had a chance to wonder about this, but the media's keyword list and her own personal psychology converge to make her prefer to see sexism. Against these force vectors she is powerless. The medium is the message, she just puts her byline at the top. Hess even looked for a "woman problem" at The Economist which I thought was going to be that there weren't enough women there because she cited the statistic that 77% of the writers are men, except that she then lamented that since there are no bylines you couldn't tell which ones were the men and the women, which was also bad. But she had something else in mind:

In many ways, the magazine suffers from the same woman problem that plagues libertarianism more widely. The Economist's central belief in "free trade and free markets" informs its one-size-fits all approach to its readership--the idea that women might actually want to consume news differently than men doesn't fit into this theoretically level global playing field.

Women consume news differently. True? Let's find out:

When I lived with a boyfriend who subscribed to The Economist, I'd pick up the magazine occasionally, scanning the table of contents for the odd piece that appealed to me--a dissection of the racial dynamics of American marriage, for example, or a takedown of U.S. sex offender laws. Typically, though, I'd flip straight to the book reviews, a space I discerned as a little more inclusive than the front of the book. I recently asked that guy whether the contents of the magazine ever struck him as particularly masculine, too. "It's called The Economist," he replied. "It's like Maxim for nerds."

Lord have mercy.

First of all, Maxim is already for nerds, who else would want to look at glamour shots of still dressed women only women have heard of? This month is Sophia Bush and Olympic figure skater Tara Lipinski, yum, time to get your hard on. "Oh I loved her with Johnny Weir covering Sochi!" Can't say Maxim doesn't know its demographic.

this is what women are told men want; this is how women are told how to want

So for him to think Maxim isn't for nerds means he thinks it's for Dude-Bros, i.e. large genitaled males who get to rape all the drunk chicks at the Delta house. Which means he's an easy mark for branding, and which, I am willing to bet $10M, is why he tells his guy friends about Maxim but shows his girlfriend he subscribes to The Economist. Don't worry, Amanda, he only reads the book reviews, too. Stab in the dark, here's a guess at his character sketch: a smart underachiever, proud he's "not some frat jerk", he knows he's supposed to be interested in topics not related to him but finds his concentration isn't up to the task-- so he reassures himself with the trappings/magazines of intelligence. "Would Adderall help me do more work and less porn?" No, but it will help you write a book of porn and you will be terrified at what you learn. His favorite way to consume news is to forgo primary sources in favor of skimming two paragraph dissections written by others who also forwent the primary sources. Unmotivated, unthreatening and unrelevant, publicly not drawing from the system according to his need but privately disavowing a lack of contribution back to the system according to his ability. "But the system is corrupt." $100M says there's a vaporizer nearby.

Second of all: hell yeah, dissections and takedowns, thank you for your consideration.

Third of all: observe that she asked him about The Economist after they had broken up. Her ex was her go-to guy when she had a question about masculinity, and magazines. Does she know any other men? Has she interacted with any men without the polarized glasses of stereotype, prejudice and fear? Is every guy only either a love interest or a Dude-Bro?

Fourth: she misunderstood/completely understood his answer about whether the magazine was particularly masculine: "It's called The Economist." Uh oh. If I ask, "Is Cosmo Magazine particularly feminine?" and you reply, "Duh, stupid, it's called Cosmo, any more feminine and it would have a tailbone tattoo," then you are implying not only that the magazine is feminine, but that I should have been able to infer that because cosmos are feminine. To him, The Economist is masculine is because economics is intrinsically masculine-- and she implicitly accepts this. Now who's the sexist? Whose theoretical daughters have a better chance of learning economics? Of course she'd say any women can learn economics, yay women, but her daughters would be learning a masculine discipline, see also math, which I predict she's bad at. The barrier is in herself, sexism is merely her projection of it.

So while she pretends that it is the male perspective she doesn't like, it is evident that it's the contents themselves that she objects to. They're boring, but that can't be related to intellectual curiosity because she's a thinker. So it has to be the "male perspective". But didn't the same male perspective write the takedowns and dissections? Books, sex, relationships; those are "inclusive to women". What happens when you don't sign up for NATO-- that's masculine. But is it? Really? I agree that most of the articles in The Economist are boring and don't "relate" to my lifestyle as an alcoholic, but I force myself to go through them like social studies homework, and most of the women who do the same are doing it as the same. The articles aren't supposed to be interesting to me, they are supposed to be important and I force myself to be interested.

However, the point isn't that she should read The Economist, the point here is that she saw sexism, which means she didn't notice this:

UNWITTINGLY, perhaps, Vladimir Putin is playing Cupid to America's Mars and Europe's Venus. ... "I have not felt this good about transatlantic relations in a long time," whispers one senior European politician.

WTF, why would anyone whisper this? Is Putin standing right there? The Economist does this all the time, citing unnamed sources while alluding to their power and significance. Of course the easy critique to make, and even this one Hess was not allowed to formulate, is that in this way The Economist conveys the impression that it has personal access to the levers of power, the way Us Weekly recasts publicists as "sources close to Kim Kardashian", shrinking the gap between the magazine and the sources and artificially widening the distance between Kardashian and us. She becomes more important and less accessible-- except through Us Weekly.

But this critique is backwards, it assumes the magazine is trying to trick its audience, this is wrong, the audience is using the magazine to trick itself. The audience wants this distance. It wants heroes, celebrities, people with power-- it wants an upper class-- and it wants them inaccessible. Envy? No, that's advertising, this is the "news." This is what happens when a whole generation's narcissism is threatened with injury-- since everything is possible, why aren't you enjoying everything?-- the personality structure becomes overwhelmingly defensive. "If I were Kim Kardashian, then I would be able to do X!" is NOT envy, flip it over and read the redacted obverse: "Only Kim Kardsahians can do X -- therefore it's not my fault that I can't!"

The Economist demo appears to want this same defense. The real trick of The Economist is that as a magazine of "libertarianism" [sic], its belief in "free trade and free markets" requires as axiomatic that these are not real. The Invisible Hand is actually attached to a benevolent class of gentlemen capitalists who have the money, the connections, and the information to best mold the world. You don't know these people, but fortunately The Economist does. Their motto, inscribed in runes over a blue moongate on Jekyll Island, is, "Be content to bind them by laws of trade. You have always done it. And let this be your reason."

Why would the The Economist's rich and powerful demo want to be ruled? Because they aren't powerful, only rich, all that time getting rich did not translate to any power, only the trappings of power. So they've postulated a fantasy power structure/NBA owners that explains why they can't enjoy their lives as they think they should-- to absolve themselves of the guilt they feel for having money/intellect/opportunities and NOT being able to do anything with it except spend it on the system-wide approved gimmicks: Trading Up, college educations, the National Bank of S&P 500.

And you say, boo hoo for the rich. That's your media approved classism talking. Does $200k/yr have more in common with $50k/yr or $1M/yr? What do your TV commercials tell you? Don't think about where the lines are drawn, think about who draws the lines.

Hess yells about a world of masculine power because she has the power to yell at it. But of course her power is limited only to yelling, she is impotent against a troll who yells at her. But her mistake is in thinking he has the power. No one has it, the system doesn't allow it. Even the mighty Economist demo feels impotent. Are they all delusional? This is the true critique of the system, not simply that one group reliably oppresses another; but that the entire system is based on creating a lack. This lack is not a bottomless hole that nothing could ever fill, but a tiny, strangely shaped divot in your soul into which nothing could ever fit: not money, not sex, not stuff, not relationships. Nothing "takes." Nothing counts. Nothing is ever right. Only novelty works, until it wears off.

This lack of power-- not power to rule the world, but existential power-- what is the purpose of my life? What is this all for? I get that I'm supposed to use my Visa a lot, but is that it? Shouldn't I be able to do more than this? Everything is possible, but nothing is attainable. Nothing tells them what is valuable; worse, everything assures them that nothing could be more valuable. That the media is the primary way the system teaches you how to want should have been obvious to Hess, she works for it, but for that same reason it was invisible to her.

You shouldn't be surprised that the only sane response to this impotence is neurosis, for which of course the system provides a psychiatric treatment that couldn't possibly work. "I need an Ambien, I can't sleep." But where did you hear that you needed to sleep?

VII.

If you're a guy, you probably don't realize the awesome pressure on women to let themselves get looked at: to reveal themselves online, to post a pic, to give everyone your attention, to stop what you're doing and give the other your self, even if they want to yell at you. "Hey lady, I hate you!" And yet that same pressure tells women they are valueless unless they are public. Madness.

The system is illogical, the things you want cannot actually coexist, but you dare not attack the system that promises everything, therefore something else must be blamed. As a basic example, Hess probably wants all the benefits of socialism and all the brand products of capitalism. When she can't have it, obviously the problem is misogyny.

Another example: Donald Sterling.

everyone hates two of these: fat cats, america, virgins

Here's a transcript of an illegal recording not done by the NSA that therefore everyone is ok with, consistent with our new standard of conduct: it is not illegal to make an illegal recording as long as it is given to the media and they profit from it and we can use it to rationalize our lives. Got it. Now I know you think you know what he said, but this time pay attention because he leaked a state secret:

You can sleep with them, you can bring them in, you can do whatever you want. The little I ask you is not to promote it on [Instagram] and not to bring them to my games.... Don't put him [Magic Johnson] on an Instagram for the world to have to see so they have to call me... Yeah, it bothers me a lot that you want to broadcast that you're associating with black people. Do you have to?...You're supposed to be a delicate white or a delicate Latina girl.

Here's a question: who is THEY who have to call him? Why is a gazillionaire 3 years from God's judgment worried about They? And why would They care what his girlfriend does? The implication is that They are even more racist than he is, which should blow your mind when you consider They are about to pretend to try to take his team away from him and give him $600M.

But the other possibility-- which coexists with the first-- is that They don't exist, not in any coordinated way: They are you, the public, far more dangerously racist than he is because his racism is overt and yours is disavowed. What he is worried about is that you will see a picture of "a delicate white or Latina" girl next to a guy with large sneakers and... film your own conclusions.

Some clueless TV types have deduced that she set him up. Duh. Then they tried to figure out why he hooked up with such a manipulative harpy, and I therefore know with 100% certainty that to them having a hot young girlfriend is an unattainable fantasy. But he didn't have a choice: his superego required it, as a condition of his identity he is obligated to have a mistress, a miss-stress-- a girlfriend who is way more headache than any wife he was "bored" with. Since everything is possible, he is obligated to enjoy-- and if it isn't enjoyable there must be something preventing it, and that obstruction has to be her fault, or They's fault, what it can't be is his fault. He's 80, his sexuality is... on the decline. If he can't enjoy sex someone else has to enjoy it for him, in his place: no, not the black guy, but her-- she is doing the enjoying for him. Being cuckolded-- that's what this is, right?-- is fine, it works for him, as long as he isn't humiliated in public. "It's ok if They see me as a racist because I AM a racist, I accept it as part of my identity, there's no shame in it; but if They think I'm not satisfying her, or worse-- if they think I'm a cuckold-- if they don't see me the way I want to be seen----"

"If only you were the girl I thought you were!" he said, paraphrased. But of course she was the girl you thought she was-- she picked you. When you pick a woman for certain reasons, you are also picking the kind of woman who wants to be picked for those reasons. You may even have succeeded in tricking her that you like her for other reasons, but this is irrelevant: you like the kind of girl who likes the kind of guy who pretends to like women for other reasons....... But in any event, his desires were illogical, they can't actually coexist, so it must be They's fault.

It is heartwarming to think of the backlash against Sterling as a new intolerance of racism, and I'm told his case is important to society because he's famous and rich, but his money doesn't come with any power. So while you are all glowing in self-righteousness because you outed another racist rich guy, consider that you will never hear a recording of the head of Goldman Sachs making racist statements. "Maybe he's more progressive?" Hmm. Or maybe power won't allow it, power won't even allow you to think about it. The more likely explanation-- remember, basketball is a TV show on The Disney Channel the outcome of which couldn't be less relevant to humanity-- is that it is projection, it represents frantic activity as a defense against change. "I'm not a racist-- because THAT's a racist!"

---

1Bbu9uvaNMWmAGj6sPF3edaA4u1wY2DLtZ

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===== ====== ===== The Last Psychiatrist: Damned If You Do... No, That's All. Damned If You Do.

In case there was any doubt that psychiatry is on the march (from Psychiatric Times June 2007):
The mass murders at Virginia Tech [sic: there was only one mass murder] could lead to harsher laws restricting [mentally ill people's] rights... Perlin, professor of law at NYU, predicted that several states will try to change the basis for involuntary commitment from danger of harm to self and/or others to the need for psychiatric treatment. [emphasis mine, but really, does it need emphasis?]
Mr. Perlin said he expects the U.S. Supreme Court will be asked to rule on such a statute's constitutionality within 10 years. "I am already counting the votes."
Me, too: Scalia, Thomas, Roberts, Alito, Ginsburg-- strange bedfellows, indeed, but Scalia and Ginsburg spend every New Year's Eve together-- against; Souter, Kennedy for; the rest is anyone's guess (Stevens may not even be there.)
The second article, from the same issue, accidentally describes the crux of the psychiatry/violence dichotomy. In "Mental Health Staff Can't Sue If Injured By Patient," the writer explains how it is rare, and generally discouraged, for staff to sue or press charges against a patient who is violent and injures them.
Patients who attack mental health professionals in hospital settings are rarely prosecuted and usually cannot be sued for civil damages [said] Ralph Slovenko, Ph.D. at the annual meeting of the American College of Forensic Psychiatry.
...Authorities usually take the position that it would be inconsistent to prosecute a person who has already been hospitalized for reason of mental illness...
... a New Jersey Court ruled [that] to convict a mentally ill person for displaying symptoms of mental illness... could not be justified constitutionally or morally.
Anyone disagree? Choose carefully. Here's the problem: the exemption from prosecution isn't for the insane behaving insanely, or the schizophrenic exhibiting psychosis; the exemption is for any patient. "Patient" in this context, is defined as anyone who is in the psychiatric hospital. In other words, it's not a label based on pathology; it's a label based on geography.
This may surprise many people, but psychiatrists hospitalize non-mentally ill people all the time. Any resident will lament how often they are confronted with the malingering drug user who fakes suicidality to gain admission. Well, if you admit him-- strike that, if he has ever been admitted-- then he is a de facto patient. If he kills you, he is automatically in a different legal status than if he murdered you in a supermarket. For example: no death penalty.
It goes without saying, of course, that even the presence of mental illness shouldn't free one from prosecution. That's why we have the legal construct of insanity.
Here's the clincher:
The situation is analogous to the "Fireman's Rule" in tort law, he said. A firefighter... cannot sue the owner of a burning building for injuries sustained in firefighting.
... I assume because a firefighter must have a reasonable expectation of fire-related danger. Fine. But if the firefighter, while fighting the fire, gets shot in the face by one of the meth-lab workers inside that the owner of the building is employing to make methamphetamine, is there no basis for a suit? Does reasonable expectation of a certain level of danger extend to, well, to volitional acts of violence that have nothing to do with the physical structure that the violence happens in?
The reason I mention these two articles together is because they are the same. "Mental illness" is a term so vague and empty that it is dangerously useless. Reducing one's responsibility, or restricting their freedom, based on such an arbitrary term is, well, insane. Doing both at the same time is a tacit acceptance of classism; that some have the responsibility to rule, and some have the responsibility to be ruled.
Oh, I know: everyone hates George Bush because he has no respect for civil liberties. Ok.

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===== ====== ===== The Last Psychiatrist: David Duchovny Does Not Exist

I read in People Magazine that David Duchovny entered a rehab for sex addiction. (I lie: I saw it on perezhilton.com.)

Duchovny's characters have often had this dark sexual side: Mulder's main outlet was porn; the transvestite FBI agent on Twin Peaks, the Red Shoe Diaries. And he's been accused of sex addiction 10 years ago (before he was married.) (He denied it.)

The timing is either coincidental or ironic, or neither: season 2 of Californication-- his show about a sex addict, starts September 28.

Which then begs the questions: is this

who he is, and chooses roles (or is able to do certain roles) based on his personality?
not who he is, but becomes it because of repeated exposure to these roles?
not who he is, but is using this as a publicity stunt?

If:

then his core identity is strong, and can only excel in roles where art imitates (his) life
core identity weak, but would be a good actor in diverse roles as well OR could be a better actor by immersing himself in a character OR he (and Tea) should be careful of the roles he chooses
core identity strong, Hollywood's products need every bit of help they can get

The image is not the real, but only a representation.   But if there is no real, then that representation becomes the real.

I don't know whether he is a sex addict/good actor/strong personality, or not. But as I've said before, everyone must ultimately choose who they are, or else it will get chosen for you.

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===== ====== ===== The Last Psychiatrist: Deconstructing a Promotional Slide Deck: Geodon

You can complain that all data is biased and all promotional programs propaganda, but until someone comes up with a better system of medical education and figures out how to pay for it, this is all we have.

My intention is not to do a Carlat "all medicines suck" style hit piece. I want to show how to do a powerful analysis of a PROMOTIONAL slide presentation, and also how to detect some of the typical tricks/misdirections. These are frequently used by academics as well.

These slides are for Geodon's new indication, Geodon as an adjunct to Lithium or Depakote for Maintenance of Bipolar Disorder. It is what doctors (will) see at promotional programs (e.g. dinners) and versions of these will become rep detail pieces (what they'll show doctors.)

I don't have the slides, but I did get a peek at them, so I've redrawn them from memory. Yes, memory.

Slide 1:

Indications ("antipsychotic") etc, are descriptors, not identifiers. 15 years ago Geodon was tested for schizophrenia, and found to be effective. Today, it is tested for maintenance bipolar; so we say "this antipsychotic is also effective for bipolar maintenance." Wrong. That's an accident of history. 15 years ago they could have first tested it for bipolar, and today done schizophrenia trials, and then we'd say, "this is a mood stabilizer that also treats psychosis." Both of those statements are empty. It is a chemical, it has utility, not identity.

Side 2:

What does the author want to be true?

This is the main slide, disguised as a throwaway. As the "introduction" it clarifies for you what is established already-- according to the presenter-- even though it may not actually be established. "As has already been established, Windows is a superior operating system."

Pfizer has decided to market Geodon for mild states, and emphasize it's better weight profile.

Their message is: "hey, even though you think Geodon is weak, nothing works as monotherapy. And we at least have an indication for maintenance."

It seems there's no way to manipulate this: two simple quotes. The second quote seems to follow from the first, i.e. because the rate of success of monotherapy is so low, therefore you need a combination. But, in fact, reference two doesn't attribute the prevalence of combination therapy to a lack of efficacy. The sentence preceding quote 2 is:

In recent years, the therapeutic armamentarium for bipolar disorder has expanded in terms of options. Hence, the clinical management of bipolar disorder now usually involves a combination...

There's combination out of necessity, and combination out of availability.

Slide 3:

Their message: "We took some manic/mixed bipolar patients, and randomized them to mood stabilizer alone vs. mood stabilizer + Geodon, for 6 months, to see which kept them stable (time to intervention) longer."

Let's work from the middle "Stabilization/Randomization" square. What were they stabilized with? Li or VPA, + Geodon. What were they randomized to? Either a continuation of that, or the Geodon was taken away.   So the study doesn't measure maintenance efficacy, it measures the speed of relapse if you take one of the two medicines that got you stable away.

Go back one step to the first circle. What happened to some of the 580 people who couldn't get stabilized, after 16 weeks, on Li/VPA + Geodon? They didn't stay in the study. Same with those who had some adverse event. 50%, gone. So by the middle square, the study had effectively selected for those patients who could tolerate and respond to Geodon.

Continuing backwards, it appears that the study begins at the big green vertical line, but it doesn't. Reformatting the slide gives a more clear explanation of the events:

You now can see that there was one extra initial step. Real outpatients on any kind of medications were screened. If they were manic (MRS>14 or 18) then they were TAKEN OFF THEIR MEDS and given Li or VPA, at therapeutic level, for 2 weeks. Those patients who DID NOT IMPROVE on the monotherapy were then given Geodon as well, for 3-4 months, until stabilized.

This effectively screens out patients who respond to monotherapy. Consider: you already know that by the end of the study, the monotherapy patients will relapse faster, because monotherapy didn't work in the first place.

Aside: this may be a question of severity, but how is it possible to let more than 600 people stay manic for two weeks on one single medication, and not intervene?

Slide 4:

Their message: "Geodon + Li or VPA was superior to Li/VPA alone for preventing relapse."

More full message: "Geodon + Li or VPA significantly increased the probability of being relapse free."

Of the 240 patents who started the maintenance phase, only 138 finished. Kaplan-Meier analysis is a way of analyzing the probability of an event (in this case, being relapse free) even when there are dropouts for other reasons. It's probably more useful to simply say this:

[during the 6 months] intervention for a mood episode was required by 19.7% (25/127) of subjects receiving ziprasidone, compared with 32.4% (36/111) of subjects receiving placebo.

...median time to intervention for a mood episode for ziprasidone and placebo, respectively,was 43 days (7-165) and 26.5 days (2-140), among patients who required an intervention (n=61).

You might be tempted to say the following: "hey, Depakote or lithium alone wasn't that bad-- 70% probability of being relapse free. So?"

What would be awesome was to have a straight placebo arm (i.e. Li/VPA + Geodon vs. Li/VPA + placebo vs. no meds at all), to compare.

Though one shouldn't compare across studies, etc, etc, compare the above survival curves to those found in the famous year long Depakote maintenance study (Depakote vs. lithium vs. placebo monotherapy trial for prevention of mood episodes-- (done by the same guy, hey. would you look at that))

In that study, the same maintenance power of depakote and lithium wasn't better than placebo.

Slide 5: Dosing

This slide does not tell you the doses used to keep people stable for 6 months; it tells you the doses used to stabilize the patient, i.e. the acute mania dosing.

It is true that they were then kept on these doses, but you don't know if doubling the dose-- or halving the dose-- would have changed the outcome of the maintenance phase.

It is already established in the acute trials that it takes 120-160mg of Geodon ALONE to treat acute mania; perhaps the 50% that only needed 80mg here had some effect of the VPA/Li; or there was better attention to giving with food here; or the permitted use of Ambien and Ativan (<2mg) also helped. In any case, it seems reasonable to say that one should not expect any acute efficacy at all under 80mg.

Slide 6: Nonadherence

Looks like a throwaway; but it's the whole marketing message. Weight gain= Zyprexa/Seroquel; Sedation = Seroquel; Akathisia = Abilify as defined in the secret Big Pharma Marketing Playbook. They all use the same copy. (Geodon would be QTc.) The slide lets you know that this is why patients stop their meds, so be proactive...

First, the actual Guidelines reviewed studies that find that denial of illness and lack of efficacy as the main culprits. In fact, they write "there is not a robust association between medication side effects and adherence... a survey of 3000 patients found that side effects ranked 7th on a list of concerns..."

But those studies aren't the point: the Expert Consensus Guidelines aren't a review of studies, they are a 40 question survey given to 40 experts in bipolar. "What do you think is the standard of care? What's your favorite Dr. Who episode?"   Also note that these experts don't routinely treat patients.

The Experts rated side effects as the main adherence issue.

The experts' ratings agreed with the findings in the literature about the importance of poor insight and lack of illness awareness, belief that medications are no longer needed, and lack of treatment efficacy as key factors that can contribute to adherence problems. It is interesting that the experts gave more prominence to side effects as a contributor to adherence problems than has been reported in surveys of patients and other studies in the literature.
Yeah, that is interesting.

Even more interesting is which side effects these Experts rated as most important, in decreasing order:

Weight gain (women)
Sedation
Sexual dysfunction (men)
Cognitive side effects
Weight gain (men)
Sexual dysfunction (women)
Akathisia
You can see that akathisia got a promotion on the slide.

Final point:the studies found that patients were most troubled by weight gain and cognitive side effects:

It is interesting, although not surprising, that the experts considered excessive sedation a more important contributor to adherence problems for patients with bipolar disorder than schizophrenia, reflecting clinical experience that patients with bipolar disorder strongly dislike being sedated.
It may very well be that Experts/academics see a population that doesn't like sedation, whereas an inner city psychiatrist might believe the only thing patients crave is sedation.

Slide 6: Weight Gain

It looks like Geodon had no effect on weight; alternatively, it looks like Li or VPA will cause 5% of patients to gain >7% of their body weight (e.g. 10-15lbs.)

But this tracks weight changes starting from the double blind phase. Remember, patients were loaded with VA or Li for two weeks, then Geodon was added for 10-16 weeks. Not to mention they were already on meds in their past. Could they all have gained 100 lbs in the first four months, only to level off in the maintenance phase? Of course. Did that happen? Who knows?

All that you can say is that after being on Geodon for 4 months, the proportion of people who go on to have even more weight gain in the next 6 months is 5%.

Slides 7 and 8: Sedation and Movement Disorders

Same deal: these are the side effects only in the last 6 months of a 10 month study. Could sedation have been massive but transient in the first four months? Could tolerance to the effects have developed? We know 50% of patients dropped out by the randomization phase-- half of those due to adverse events. Did the people who experienced sedation or movement disorders quit?

The study had effectively screened for patients who could tolerate these kind of side effects, so you'd expect them to be low in the last half of a study.

Slides 9 and 10: Discontinuation/Tolerability

Same deal, again.

Please take a moment and look at the slides as if it was your first time. Despite the clear labeling "At 6 Month Phase", you can't help but think "rates of adverse events were low."

If you're astute, you might even think, "weird, people on two medications actually had fewer side effects, lower discontinuation rates." And your mind would start speculating: well, the Geodon is actually a little activating, so it counteracted the sedation that was caused by the Depakote."

No. The Geodon doesn't counteract the sedation; nor are there really "low rates" of discontinuation. Remember, 50% of the people stopped the combo even before randomization, and 50% of those stopped specifically because of an adverse event.

So Slides 9 and 10 are showing you the rates of AEs in people who had already tolerated 4 months of both medications.

This is important and must be understood. Content-- whether it be a Pharma slide or a newspaper article or anything else-- is almost never factually inaccurate. But the story, the style, the presentation is intended to get you to lie to yourself. This slide very obviously says, "in the 6 Month Phase." There's no misinterpreting that-- and yet you did.

Don't blame yourself entirely, it is a trick. If the slides were presented with the intention of imparting information (instead of a story) then it would never have shown you only the Phase II data, it would have offered you something like this:

which comes from the study itself.

But don't get excited, the studies are almost never more honest than the Pharma slides. The above Subject Disposition tree is a very recent phenomenon in articles, forced on it by an exhausted readership, and many articles still don't use it. Not that it would make any difference: no one reads the articles anyway.

Slide 11: Geodon Must Be Taken With Food

The FDA recommends test meals for medication studies, but specifically two: high fat (50% of calories from fat) and high calorie (1000 calories.)

It isn't clear from this slide what constituent of food is necessary to the absorption. Some foods need specific conditions for absorption (e.g Vitamin C needs an acidic environment and absorption is reduced by fat.)

Geodon is highly lipophilic, so it would make sense that fat is key to absorption. Nope:

Low, medium and high calorie diets are 250, 500, or 1000, respectively.

Fat appears to have little to do with it. Calories matter, thought the benefit appears to maximize at 500 calories-- doubling to 1000 calories is only marginally better.

What isn't known is whether the effect is due to pH, transit time, or some other factor.

The simple problem is that to get Geodon to work you need 120mg or so, and it has to be taken with food. Any claims about lack of efficacy before these two conditions are met are just plain silly. They should have made a slide with that, but they didn't.

Slide 12: Dosage Adjustments Are Not Necessary With Geodon

(I found this slide on the internet and saved myself an hour with MS Paint.)

This slide is often presented with another showing specific drug inhibitors/inducers (ciprofloxacin, phenytoin, etc.)

While theoretically legitimate, it mostly doesn't have enough of an effect with antipsychotics to matter. So there's little point to learning it, though the idea that Geodon is metabolized differently and has little effect on/from liver metabolism is good to know. (But there is a cardiac effect with other QTc prolongers.)

A better way to use this information:

Smoking cigarettes can dramatically reduce some antipsychotic levels. It can cut Haldol in half, and reduce Zyprexa by 40%. But in ordinary practice, that doesn't matter-- you'd have instinctively given the patient more mg because he's not better. You may not realize that you did this because the drug level is lower (not that he is sicker), but ultimately it doesn't matter.

Where it does matter is a hospital, where patients aren't allowed to smoke: psychotic patients is stabilized on 10mg Zyprexa, he gets discharged and goes back to smoking a pack a day. See?

So what really matters is changes from the usual. It's important to know that a guy takes HCTZ and smokes 2pp/d, but it's just as important to know if that status changes.

In my opinion, every opportunity should be taken to lower dosages or stop medications. If a guy quits smoking for real, I try to cut his Zyprexa in half. "Really?" Yes, really. The liver tells me to. If a patient "shows frequent noncompliance" with a medication but otherwise seems stable, I don't encourage them to comply. I reduce it or, if it's an SSRI, stop it entirely.

Slide 13: FDA Warning

WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. GEODON (ziprasidone) is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Precautions].

First, this is a warning about dementia related psychosis, not about being elderly. An 80 year old man with bipolar disorder does not have this risk; a 55 year old with dementia related psychosis does. (More accurately, no studies have found a similar mortality in elderly patients without dementia related psychosis.)

Nor is it even clear what the risk is: as many of these patients died of cardiac events and infections, it can't be blamed on a direct brain effect.

The warning was based on deaths reported in the 17 trials (5000 patients, aver age 81) using the six atypicals. Importantly, these were short term studies: the increased risk of death happened in 6-12 weeks.

Two observational studies found conventionals had the same risk.

There are numerous questions to ask, I'll ask two you might not have thought of:

The 17 trials were in 2002-5. Assuming Geodon was shown to have the same risk, how did it cause the risk if it was (probably) dosed low and without adequate meals? Is it therefore dose independent? Or is the mortality due to something else? Similarly, 5mg of Haldol is "more" antipsychotic than 5mg of Zyprexa, but less anticholinergic (etc.) If both of those carry the same risk (studies were not powered for this) then it suggests something else is the cause.
I know these studies were mostly done in nursing homes. Were they mostly done by psychiatrists? Imagine an agitated patient gets a pill-- placebo or antipsychotic. Does the calming effect of the atypical delay a cardiology or infectious disease consult by a day or more... while the placebo patient appears sicker, so gets an EKG or CT faster? Remember, the average age is 81. How much time to you need to go from bad to dead? In other words, is it a function not of the medication, but of what I'm calling intervention bias: "we did this, let's see how it works before we do something else."

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If you liked this (and enough people link to it or click to it), then I may do one for all slide decks/promotional materials, and put it into an email newsletter.

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===== ====== ===== The Last Psychiatrist: Deja Vu

I had a patient with a chief complaint of deja vu, so I looked it up. (BTW: turned out to be undiagnosed dementia in my patient's case.)

Best article I found was Wild E. J Neurol. 2005 Jan;252(1):1-7. Summarized (and all below references come from Wild's paper):

Definition: "any subjectively inappropriate impression of familiarity of a present experience with an undefined past." (Neppe, 1983)

Wild explains that the definition here is importantly specific: "subjectively inappropriate" means that the patient understands the familiarity is impossible (i.e. this is not a delusion.) "Undefined past" is a non-existent past, and the patient never pinpoints it (because it never happened).

Some theories:

Wigan (1985), Jensen (1868) and Maudsley (1889): a "loss of synchronicity" between two hemispheres of brain, so that they are working "separately but synchronously." Jensen also suggests it is familiarity of one part of the experience generalized to the whole.

Gestalt psychology: object-affect entities. An experience causes an affect, which is identical to the affect assocaited with an unrelated event in the past. Your brain interprets it as a rememberance of the object (as opposed to the affect.)

De Nayer:"tape recorder hypothesis:" you are remembering the event and recollecting the event at the extact same time.

Freud: the situation is similar to a suppressed fantasy, so the fantasy activates as a wish to make improvements in the current situation, so in essence it is the wish to turn back time.

Biology:

Associations with temporal lobe epilepsy suggested that that was the relevant neuroanatomy, but some interesting experiments suggest that deja vu is associated with limbic structures (especially hippocampus and amygdala) and not the temporal neocortex itself. Bancaud (1994) tried to synthesize the available information and proposed that the perception is encoded in the temporal neocortex and remembered in the hippocampus; affective memory is supplied by the amygdala. Then, these relate back to the temporal neocortex as a daja vu. Thus, a situation, as it is experienced and "recorded" (see De Nayer) activates deeper memory structures.

All of this appears to be lateralized to the to the temporal lobe ipsilateral to the dominant hand (which is really the non-dominant hemisphere-- it crosses). In fact, the point of all this was to use the symptom of deja vu to predict where a seizure focus would be. (Unfortuantely, a PET scan study could not confirm this lateralization.)
Because of the prominent association of deja vu with autosomal dominant "partial epilepsy with auditory features" a genetic contribution is suggested. This gene is the LGI1/epitempin gene (10q24).

Assessment should rule out depersonalization or flashbacks. If deja vu is short or infrequent, it is probably normal; but if recurrent, prolonged, or associated with physical sensations, consider TLE. If associated with anxiety or depression, consider psychiatric causes.

Other articles:

A study of 24 epileptics receiving direct stereotactic electrical stimualtion of the brain found that stimualtion of the entorhinal cortex produced more deja vu than the amygdala or hippocampus, while the perirhinal cortex was associated with the recollection of memories.

A prospective study of TLE patients and their "auras" (called simple partial seizures, i.e. seizures with no loss of consciousness, and include deja vu, weird tastes, etc)) found that the SPSs, deja vu, a warm sensation, a cephalic sensation, taste hallucination, and a "strange" sensation predicted an abnormal amygdala ipsliateral to the seizure focus. Though fear was the most common for all TLE patients, the single best predictor of an abnormal amygdala was... deja vu. As described by Wild, this occurred most commonly on the right (i.e. ipsilateral to handedness, or nondominant for language.)
A study of 14 patients with varying frontal lobe damage were tested for a number of memopry parameters; those with incorrect "feeling-of-knowing" had damage in the right prefrontal cortex.

Although deja vu is supposedly distinct from psychosis, and not related to dopamine, there's a case report of a 39yo physician-patient who took amantadine and phenylpropanolamine to ward off the flu, and got intense deja vus. They stopped when he stopped the medications. The authors find other case reports finding the same.

An interesting case report (two cases, actually) found that, contrary to the popular understanding that the deja vu shares some similarity to an actual past event, on formal testing these two patients had recollections which were unlikely related to previous familiarity ("incorrectly recognised low frequency words."). They then created justifications, i.e. they confabulated the recollections.

As an aside, there are 85 articles in Pubmed with the words "deja vu all over again" in the titles. Almost none actually had anything to do with deja vu. That's creativity for you.

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===== ====== ===== The Last Psychiatrist: Delaying Gratification Is Easy If You Don't Try

One marshmallow or two?

The New Yorker has an article about the famous Mischel experiments.

A researcher offers a four year old child a marshmallow. He is told he could eat one now, or, if he is willing to wait until the researcher returns from running an errand, he can have two marshmallows.

Some children eat the marshmallow as soon as the researcher leaves. Others can delay for varying amounts of time. About 30% are able to patiently sit there for up to 15 minutes, holding out for two marshmallows. How?

I.

Mischel doesn't see this as a test of willpower, but as a test of the cognitive ability to determine what works, and what doesn't, to delay gratification.

Breaking it down, there are two actions in play here: the first is the action of waiting for the man to return. The second action is not eating the marshmallow. It is this second action that Mischel thinks is important in succeeding: "strategic allocation of attention." The best way to avoid eating the marshmallow is to not to think about it.

Kids who can delay gratification have an intuitive understanding of this. So they cover their eyes, sing a song, etc. The kids who can't delay do/did the wrong thing: they stare at the marshmallow, trying to beat it in a battle of wills.

To emphasize: it is not that some kids have more willpower, but that they have a better ability to think about something else. More precisely: they have a better ability to know that distraction is what will work.

II.

Mischel describes ways to improve delay, e.g. watching videos of other kids successfully waiting.

"This is where your parents are important," Mischel says. "Have they established rituals that force you to delay on a daily basis? Do they encourage you to wait? And do they make waiting worthwhile?" According to Mischel, even the most mundane routines of childhood--such as not snacking before dinner, or saving up your allowance, or holding out until Christmas morning--are really sly exercises in cognitive training: we're teaching ourselves how to think so that we can outsmart our desires

III.

It occurred to me that a more obvious way of delaying gratification would be to show the kid what the reward is. Staring at one marshmallow but having to imagine the future reward of two marshmallows perhaps is too abstract for a 4 year old. Better to make the reward real: show him one marshmallow and a pair of marshmallows and tell him if he waits he gets the pair. Show him what he has to look forward to.

I dug up Mischel's papers, and it turns out Mischel did show them both choices (e.g. two cookies vs. five pretzels; one marshmallow vs. a pair of marshmallows, etc) so the reality of the reward was not an issue.

However, I was in for a surprise:

The results were the opposite of those [we researchers] predicted: attention to the rewards consistently and substantially decreased delay time instead of increasing it. Preschool children waited an average of more than 11 minutes when no rewards were exposed, but they waited less than 6 minutes when any of the rewards were exposed.

Showing them "what they could look forward to" consistently sabotaged them. Take that, "anything but" virgins waiting for marriage.

I wasn't the only one fooled; mothers of preschool kids also erroneously predicted that seeing the future reward would be helpful. Reality, apparently, doesn't encourage you towards the future; it's a reminder that you are hungry now.

(So if parents are trying to teach their kids how to delay gratification, then they should be doing it with the temptations/rewards in plain sight, so as to make the training more difficult.)

IV.

If seeing the reward makes it harder to wait, what does help?

What helps is seeing an abstraction of the reward.

This would mean seeing a picture of the reward; or thinking about (in the case of marshmallows) clouds, or (in the case of pretzels) long sticks. This is subtle, but important; doing any of these is even better than completely distracting oneself from the reward. It's almost pornographic; you're entertaining yourself with abstractions of the thing, which is sufficiently interesting to you that you're not actually thinking about the real thing. (Virgins, start your laptops?)

The longest delay time (almost 17 minutes) occurred when suggested thoughts were also about [non-reward] objects but with regard to their arousing qualities (for example, children waiting for marshmallows who had been cued to think about the salty, crunchy taste of pretzels.)
But it all comes down to distraction. In order to get the better, but delayed reward of two marshmallows, instead of just the immediate one, don't look at any of the marshmallows.

V.

But then I had another thought: why doesn't the kid just eat all three marshmallows?

Think about this. The game here is to maximize the reward; the delay is specifically for that purpose, it serves no benefit in itself. A child looking at this scenario should be able to see that the choice is really between eating all of them vs. participating in some bizarre nonsense contrived by an adult that always results in getting only some of the marshmallows. Even a puma knows not to play this game.

Any kid who holds out for two isn't choosing two over one, but two later over all three now-- and that part isn't even conscious.

This means that the marshmallows are not the only motivators. There is a value to obedience, that exists in four year olds but not in pumas. This value may be less than the marshmallows, but it isn't negligible, it isn't even small. In fact, to some it is worth two marshmallows. and fifteen minutes of time.

Evolutionary psychology, economics, and behavior studies in general often fail to account for what may be an innate, or strongly socialized, motivating variable. "Rational people will seek to maximize their gain." Sure. Now define gain.

In many discussions about behavior and economics, we do not account for obedience and social pressure. This is a mistake, as it is evident that it is a highly significant, though invisible, determinant.

===== ====== ===== The Last Psychiatrist: Desmond's Teleological Suspension of The Ethical-- Or My Novel?

A few weeks ago I had used a Lost storyline to explain my own view that we pick our own identities, rather than have them given to us through either genetics or the environment. I made Desmond the Abraham in Kierkegaard's Fear And Trembling.
The crux of the episode and the analogy is that Desmond thinks he can see the future, and see that Charlie will die.    But Desmond then makes a vital moral step: he decides that it is also his responsibility to keep this character alive. (Quoting myself:)
The real question is why Desmond actually believes such a choice exists. How does he think he knows the future?   Anyone else in his shoes would have come to a very different, more logical, conclusion: this is insane. What, he can predict the future? Worse: what, he's the only reason Charlie is alive? He's so-- necessary? Isn't that narcissism?
If Desmond knew he could predict the future-- if it was a fact that he could predict the future-- then saving Charlie would have little moral heroism. Any fool a step up from absolute evil would have tried to prevent a horrible outcome if he knew for certain what was going to happen.

What made Desmond worthy of admiration was, exactly, that he did not know for sure he could predict the future. He took it on faith that he could, and then proceeded to live his entire life based on this single, faith based, assumption.

That was Feb. 15. Strangely, I just saw last week's episode, in which Desmond turns out to have once been a a monk, and he has a discussion about Abraham and Isaac with another monk; the wine they make is named Moriah; and later Desmond explicitly references the test of faith-- straight out of Fear And Trembling.
I suppose this could be a coincidence.
Another possibility is the writers read and and love this blog and have gone and reshot future episodes based on my ideas. HA!
Another possibility is I write for Lost. HA HA!
But the final possibility is the most likely, and it has less to do with Lost and more to do with the direction of our fiction.
Pre 9-11, fiction, and especially sci-fi, had a distinctly post-modern flavor. The main character wasn't really a person, but reality-- that it was wrong, or hidden. This culminated in the Matrix. The important concept wasn't altering reality for some purpose; it was that reality itself was a fabrication, the Demiurge hiding real reality behind a fake one.
The story goes that Darren Aranofsky (director of Pi) and Jared Leto walked out of the Matrix and asked, "What kind of science fiction movie can people make now?" The point was that the postmodern slant, cyber-realities, etc, were done as well as they could be. So, too, CGI. From now on anything else would be coattail riding. (Think how Pulp Fiction degenerated into Go and 2 Days In The Valley.) The genre was finished.
So what's next? Well, for Aranofsky the answer was the mind (see The Fountain), but I'd suggest an even broader answer: ideas. The next genre of sci-fi, or fiction- has to be about the conflict of ideas, identities.
If I was going to write a novel-- and who says I'm not?-- I'd take advantage of our societal narcissism, our search for identity-- and, more importantly, for excuses why we have certain identities; our fear of death manifesting as age-postponement; and the decline of truly meaningful relationships to write a sci-fi novel about what really keeps us linked to each other.
The operative question would be: if you could be anyone, had unlimited power, what would be the ethical system you use to make choices? Who lives, who dies, who suffers, who doesn't? How do you decide?
The first element would be Faith. So, with a parting wave to postmodernism, the protagonist can see the future or alter reality, except that he's not sure he can do this. Worse, every time he alters reality by avoiding a future he has supposedly seen, he creates a new future he didn't predict-- but this is, of course, no different than normal life. In other words, by avoiding the future he predicted, he negates the proof that he saw the future. So he has to have Faith that he has this power, in the absence of any evidence. The protagonist of my book won't have any objective evidence that he is right or doing the right thing, he simply will have to believe, to decide, that he's right. It has to be identical to, say, psychosis.
In Lost, Desmond still has objective evidence that he predicted the future, even though it gets altered; he sees an arrow; they did talk about Superman; the parachutist looked the way he foresaw it. So this isn't exactly a leap of faith. Similarly, if Abraham really knows God exists, then sacrificing Isaac isn't wrong or even strange-- God wants, God gets.
Unlike Desmond, who has to decide only if he should save Charlie, my character would have to both decide he can see the future, and also that it is his responsibility to act on it. This brings us to:
The second element, Duty. In making these decisions and accepting these beliefs-- altering reality along the way-- he'll have to establish a hierarchy of good and bad. What is he supposed to do? Does he have any duty towards anything? For the plot, this will require some symbol, metaphor. A good one might be a piece of jewelry-- some object which changes depending on the chosen duty. It's a ring, it's a sword, it's a bandage, etc-- it's the same "object" that he carries, but it changes.
The third element is Rage. When you believe something that no one else believes-- especially if you believe you are somehow better, or even different, than others; and if others directly oppose you in this belief, the inevitable consequence is rage. How to depict this?
The fourth element is Love. The negating force for Rage. This character will need to identify what he loves, and how-- platonic, romantic, etc; a plot-trick might involve altering reality and therefore altering the character of his love (for example, a woman he loves may later become his sister, etc.)
To make the reader share the magnitude of the protagonist's Faith dilemma-- in order to ensure that the reader does not "suspend disbelief" and automatically buy into the protagonist's powers (the way we have with Desmond,) you'd have to write the book from the perspective of a second character, who describes the story of the protagonist. You should never actually get to interact directly with the protagonist, you should never actually hear him speak, only this second character.   This way, you're never sure what to make of the protagonist or his adventures.
Preliminary thoughts, anyway. Looking forward to the next Lost and JJ Abrams stealing my ideas. ;-)

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===== ====== ===== The Last Psychiatrist: Deus Ex Homonymia
Answer the following questions, and don't look at the next until you answer the previous:

Does depression in kids raise their risk of violence?
If a kid is violent, is it more or less likely they are depressed?
If someone is depressed and violent, is it likely they are a kid?
Can you define any of the nouns in the preceding questions?

In a study called Perceived Dangerousness of Children With Mental Health Problems and Support for Coerced Treatment the perceptions of 1100 members of the public were evaluated, finding:

Children... with major depression were perceived (by 81%of the sample) as somewhat likely or very likelyto be dangerous to themselves or others, compared with childrenwith asthma (15%) or those with "daily troubles" (13%).

and, later:

...compared with the child with "daily troubles," the vignettechild with depression was more than twice as likely to be assessedas dangerous toward others and ten times as likely to be assessedas dangerous toward himself or herself.
Now, you lose no money assuming the public at large merely guess at probabilities. So what they think may be right, wrong, both-- who knows. But whatever they think, it's probably important to quote them correctly:

"The issue that was highlighted by this study that was really concerning to us was that Americans have linked depression in youth and violence, particularly violence towards others," said Dr. Pescosolido ["distinguished professor of sociology, Indiana University."] [emphasis mine, but, face it, really theirs.]
Well, no, that's not what the public thinks, at least according to your study. They think that depression leads to violence against themselves, and maybe towards others. Only 9% thought violence towards others was very likely. The majority thought violence towards others was not likely. Right?

Also, please note the subtle cut against "Americans," those barbarous, judgmental, yellow ribbon tying NRA members, i.e. "Texans." (I know, sociology professor...)

"It's really, really horrible. Many people who are not in the field perceive these youths as dangerous-- and yet we have no evidence that these kids are any more dangerous than youth randomly picked..." said Dr. Kelleher, professor of pediatrics at Ohio State.
Wow. I had thought the entire infrastructure of psychiatry rested on the very foundational idea that psychiatric disorders, especially depression, are responsible for increased risk of violence to the self. And these quotes are even more weird given that they come from Ohio and Indiana-- the two states responsible for over half the increase in female youth suicides in the whole country. You know, the increase that everyone is blaming on antidepressants.

But words are lies, and you can use loose language like "violence" and "dangerous" and "youth" and "kids"-- bending its meaning to whatever you need it to mean at that moment-- to make any point you want. The actual arguments for this position can be be flipped when necessary (e.g. Nasrallah saying a school shooting isn't "evil" but "medical illness.") You can do this if you manipulate words, e.g. conflating school shooting and suicide to "violence," and then making "violence" mean what you need it to mean at that moment.

So what is her point? I'm sure she doesn't want to be saying that depressed kids aren't prone to self harm. So?

So nothing. She, they, don't have a point, they want to convey a feeling, a political position, something like, "no one is bad just because they are sick; but if they were bad, then it was because they were sick."

It's a good position, given that it is entirely empty, and can be made into whatever you want. Right or wrong is precisely besides the point.

So what do these authors tackle next? Forced psychiatric treatment, of course.

Next...

===== ====== ===== The Last Psychiatrist: Diana Chiafair 's Hot, but Is She Illegal?

from Pharmagossip, but also Dr. Peter Rost's site, edrugsearch (which actually has several rep-models), etc, etc. She's a rep from Miami (where else) who won Miss FHM 2006.
Meanwhile, Sunderland at the NIH plead guilty to "conflict of interest" charges-- he had received about $300k over 5 years from Pfizer while he was a director at NIH, but never disclosed the money.
All of medicine has rules about disclosing financial relationships. Any academic center, for example, requires you to list all financial entaglements that could be perceived as conflicts of interest, including grants, honoraria, stock holdings, etc. The idea, of course, is that money can exert undue influence, and at the very least the people around you should be aware of any potential conflicts of interest.
This includes conflicts of family members. If you are giving a Grand Rounds about how Zoloft is better than Lexapro, but your wife is a Zoloft rep, you could be benefiting financially by getting people to write more Zoloft which gets her bigger bonuses, so you have to disclose this relationship.
But if you are dating a Zoloft rep, you don't have to. There would be no way you could be profiting financially from her increased sales, and thus no need to disclose that relationship.
But there's the cryptosocialist hypocrisy. If it was really about protecting the public from conflicts of interest, we'd have to disclose dating reps as well. History is full of examples of people behaving unethically for the sole purpose of bedding a woman. Want examples? They all come from politics. Still want examples?
So why aren't we worried that I'm praising Zoloft because my rep is hot? Perhaps we should mandate all reps be ugly? You know, to protect society?
This sounds silly not because hot reps don't have influence, but because we're lying: it's not the influence that actually bothers us. It is specifically the money. "It's not fair that a doctor gets all that money from..."
So let's stop kidding ourselves, it's not about protecting the public after all; it's really about resentment that the doctor makes so much money off the people; that they get sent on trips first class while others can't afford healthcare; about the rich getting richer at the expense of the poor. &c., &c. Pick up any copy of the New York Review Of Books for further examples.
Taking the convenient moral high ground just because it has better soundbites ("the public has the right to know!") and saves us from having to perform any critical thought is lazy and unproductive. If you want to argue that doctors make too much money or Pharma's profits are excessive, we can go down that road and try for an honest and productive debate. But let's stop pretending these disclosure rules have anything to do with protecting the public from bias. They have everything to do with the current zeitgeist of income redistribution and class warfare.

---
As an cultural observation, look for the drug rep to become the next fetishized job, like cheerleader and nurse.   A profession becomes sexualized not because the members are themselves hypersexual, but because they represent a particular balance of the "unattainable slut:" "sleeps with everyone but me." "e.g. the only reason that bitch (nurse or rep) isn't sleeping with me is that I'm not a doctor." In this way suppressed misogyny is given a cover story to make it acceptable. It's narcissism protected by an "if only" delusion. Violence is never far behind.

--- And there's your free association bringing me back to what I was really thinking when I saw Diana Chiafair's photo: marxism and healthcare reform. Hot rep--> fetishized--> commodity fetishism. Because we never see the labor that went into the objects, we never see that social relation; the laborer disappears, all that is left is the commodity to which we ascribe value-- fetishize it.

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===== ====== ===== The Last Psychiatrist: Did BP Fake A Picture? Yes, But We Did Even Worse

what's wrong with this picture? Answer: half of it is missing

Did BP fake a pic?

Yes. Why? Probably to make them look busy. They placed it on their press page.

By now you've no doubt seen the original photo. Where did you see it? Think hard. I saw the story about the photo being detected on Americablog in the Washington Post. Is that where I saw the original?

No.

Maybe I saw it on AP? Chicago Tribune? LA Times? CBS? Nope. They either show you only the altered photo, or no photo at all-- just the headline, "What Did We Tell You: BP Is A Bunch Of Lying Bastards."

Where you see the original is on blogs. Americablog detected the alteration, and have multiple shots of the original and a guide to alterations. Gawker and Gizmodo are writing about the alterations, so the originals and details are there. Why do I have to go to blogs to get a fuller story than on the Washington Post?

Sure, the news links to the original, but that's not the same thing. If the news media was serious about being serious, they would ALWAYS present the altered photo along with the original; and NEVER simply as a scary headline.

But if you do that, then there's no story.

There's no hesitation in showing both an original and the alteration when doing so tells the story they want to tell, e.g.:

(MSNBC) "Plus sized model 'shocked' at being made to look thinner"

New York Times:

In this NYT article, they quote from the apology from editor of The Economist:

I asked for [the alteration] because I wanted readers to focus on Mr. Obama, not because I wanted to make him look isolated. That wasn't the point of the story.
Maybe; but it was certainly the point of the New York Times story to show that he wasn't alone.

I chose these two examples not because of their power but because they both occurred this month. It's not like there's been any time for standards and practices to change.

But showing both BP images simultaneously is dangerous. On the one hand, it proves there was an alteration; on the other hand, it proves the news media is petty. "Are you guys just looking for any reason to jump on BP?" Best just to show the alteration with a catchy title, and let the mind run with it.

The major American news outlets aren't writing a story about a picture that was altered, and the context of that alteration, and perhaps the cultural/political significance of that alteration in an objective manner befitting The Froth Estate. They are instead writing a story that panders to the bottom level of American tastes, the populist meme of the day, "big business is screwing us!" I already knew that; I guess I was hoping the press would be better.

Doing it this way gives the Post plausible deniability. "We didn't lie to you, we just reported the facts. We did our jobs admirably." Yes. You gave us all the tools we need to lie to ourselves.

----

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: District 9
The only thing I learned from two viewings of this movie is that South Africa is the stupidest person in the world.

I know hating this is like hating Sophie's Choice in that it brands me as some sort of anti-intellectual white supremacist, as opposed to an intellectual white supremacist, but this movie was so maddeningly stupid I actually had to leave early to light up a cigarette and stab out my eyes. Then I threw myself in front of a Prius.

"But the CGI is awesome." It was awesome in Tron, for its time, too. If you take out the CGI, you're left with a movie written by Roger Hargreaves about characters whose behavior and choices make no sense at all, ever.

II. Going For Oscar

But reviews of the movie have been overwhelmingly positive, not "awesome fight scenes" positive but "scathing social satire" and "indictment of man's inhumanity to man" positive, which makes me wonder if they saw a different movie? Or did I miss the real meat of the film because I left early when I realized this was not the sequel to V The Final Battle?

So I decided to try again, I told myself that there was going to be porn at the end of it, took off my pants, and watched. No, I didn't go back to the theatre; fortunately, the major studios have joined together and created a website called "The Pirate Bay" which allows you to watch a movie for free before you decide if you want to buy it from Amazon for 4 bucks.

On the second viewing I was able to see what all the fuss was about: this is the kind of movie the Oscars love.

Oscar Loves: Innocence Lost

The movie is about a race of aliens who do not speak English but do, unusually, speak Bantu, who park their spaceship above the city of Johannesburg and do nothing. The U.S., Russians, and Chinese choose not to get involved with this spaceship, respecting South Africa's sovereign borders and trusting them to be the Earth's ambassadors.

The central story concerns a little alien boy, whom the humans disparagingly refer to as "District 9," and his father, District 8, who escape to the set of Slumdog Millionaire and look for scraps to use to build a spaceship which will fly them back up to the mother ship. The kid has the technological know-how to build such a spaceship and later pilot it.

However, his father has to explain to him what "fuel" is, and where it goes. That conversation occurs while the kid is actually synthesizing the fuel in their basement lab.

Also, the kid doesn't know how many moons Earth has. You could say that since he's not from Earth he can't be expected to know how many moons Earth has, but I'm not from France and I know how many moons France has. If it was his father who didn't know, I could speculate maybe he's nearsighted or doesn't know how to count past zero, but the kid was born on earth, he's been here all his life.

At first I had thought this was a plot hole; but on second viewing I realized that the kid is meant to be retarded. Not full on retarded, not Down's Syndrome or Brad Pitt retarded, but Forrest Gump retarded. In other words, Academy Award winning retarded. Smart enough to build a spaceship but retarded enough that women will secretly want a man like him, right after they finish getting boned by a football team. This, of course, is a pointed critique of the Bush Administration.

Oscar Loves: Racism

Everyone knows that this movie is complex allegory about apartheid. What they may not know is that since target audience for the movie is the Academy of Motion Pictures, the movie delivers this message with the subtlety of getting bludgeoned with a pizza oven.

Or so I thought, at first; but then I saw the magic of the movie's subtext. The movie is a cinephile's Finnegan's Wake, a movie full of dream-like connections waiting for a postmodern deconstruction, or two guys with some weed.

The aliens, who in the movie like to eat cat food, represent blacks. If this thematic conceit startles you, you're going to want to take a Xanax before you hear the rest of it. These aliens are descended from the original Predator alien, a Rastafarian originally named Snoop Dogg, originally played by action star Jean Claude Van Damme, who, of course, is originally from South Africa. He quit the movie because the mask was too heavy, and the role went to a black guy named Bigfoot who then died of AIDS. (1)

The South Africans find that the aliens' weapons can only be used by those with alien DNA; but they also quickly discover that their own DNA makes them hate black people, in this case aliens. So they decide to herd them into a ghetto and fence it off. The writers of the movie cleverly mask this devastating critique of the Bush Administration by naming the ghetto "Gaza."

"District 9" is an allusion to the 9th district of New Orleans submerged by the movie Hurricane Katrina almost exactly 4 years ago; for this reason the aliens in the movie are referred to as "prawns." As everyone knows, prawns are delicious; this is why some of the black people in the movie try to eat them. This entire subtext is a blistering critique of the Bush Administration who, as early as 2001, had advocated for eating Katrina victims. As the President of the Academy of Motion Pictures once said, "George Bush hates black people. Especially delicious Iraqis."

The aliens are largely forgotten and ignored in the slum, despite their being, well, aliens, a fact you could be forgiven for assuming would prompt some curiosity. Not in South Africa. Blacks there are rarely considered curiosities. The only reason the South Africans begin worrying about them after 20 years is that the aliens start having sex with their women. Amazingly, that part isn't a joke.

Oscar Loves: The Secret Purpose of War

Here's a sure-fire plot to get an Oscar nomination: a story about the greedy South Africans, played by America, who try to evict all of the Districts out of their ghetto in order to build a Disneyland, as seen through the eyes of a child. This bit of eviction nastiness falls to Wikus van der Merwe, played by Blackwater USA (Best Supporting Actor nomination), who is so craven and petty that at one point he turns into a giant robot. This transformation is a scathing critique of the Bush Administration, who hate robots.

District 8 and 9 have no choice but to turn to the underworld, the "black" market, for the parts they need to build their spaceship. Because there are absolutely no such criminal gangs anywhere in South Africa, the Districts must travel all the way to Nigeria to find thugs willing to sell them the parts.

All the while, they are relentlessly pursued by Wikus and the Fox News team, who shoot and kill everything in sight just to feel the blood splatter on their faces. It nourishes them. They also want to get access to the aliens' weapons, which are infinitely more powerful than human weapons and which are laying around discarded everywhere in Johannesburg. The Districts themselves never use the weapons that they brought with them from space on their human pursuers, because they are a peaceful race, abhor war, and just want to return to their homeland. They do, however, throw rocks at them as they're being shot at by machine guns. Also, one dons a suicide vest and blows himself up in order to kill all the vampires. I'll admit that I may be confusing this with something I saw on CNN, but it could have happened in this movie, too. And as anyone with enough weed will tell you, umm... what? Either way, I think we all know what it says about the Bush Administration.

Oscar Loves: Finales That Make No Sense But Bow To the Political Fashion of The Academy That Particular Year

In this movie, not only do many humans die-- which prompted one not at all young but in all likelihood retarded moviegoer who had stumbled in from the next door Mrs. Field's Cookies to agree, "blast those motherfuckers!"-- not only are all humans depicted as corrupt Halliburton employees deserving of and receiving of death, but there is only one human in the whole movie who displays any goodness or nobility-- but he does so only after he becomes an alien. Think about this. I wish that there was a joke in there somewhere, but there isn't.

(1) You're not going to believe this, but that paragraph is almost completely true.

------------

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: District 9 Now Elsewhere
Maybe someday...

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===== ====== ===== The Last Psychiatrist: Do Antidepressants Induce Mania?

No.

This myth is the result of imprecise use of language. Many2 3 4 5 6 have detected a temporal association between the use of tricyclic antidepressants and episodes of mania in patients with bipolar disorder, though no plausible mechanism has been suggested, much less found. It has been assumed that this association could be extended to all antidepressants despite their substantial chemical and pharmacological heterogeneity. However, such an association between mania and selective serotonin reuptake inhibitors has not been found. In fact, the studies 7 8 9 which have been done strongly indicate that the rate of mania with SSRIs is no different than the normal switch rate of bipolar disorder. A recent study10 11 of venlafaxine, sertraline and bupropion found a 13% 10 week switch rate into mania or hypomania (excludes symptoms lasting less than 7 days), and an 18% one year switch rate, but this study was confounded by the concomitant use of mood stabilizers of dubious efficacy (lamotrigine, gabapentin, topiramate) in 22% of the patients, and the lack of a placebo arm to establish the baseline switch rate. Because of the significant phenomenological heterogeneity of the patients with “bipolar disorder” in clinical trials, a placebo arm is vital in order to compare results in different studies.

It must be reiterated that these are studies of temporal associations between mania and antidepressants, and no causal link can be inferred. Despite this, many continue to discuss the question in terms of the induction of mania by antidepressants. This betrays a bias that is supported neither by data nor logic. For example, studies of novel antidepressants cite rates of “induced” mania, while studies of antiepileptics discuss “breakthrough” manias, automatically presupposing a difference in the mechanism of mania. Similarly, it is popularly assumed that bupropion is less likely to induce mania than SSRIs. This assumption is formalized in the Expert Consensus Guidelines 200012, where bupropion “was clearly rated as the antidepressant least likely to precipitate an episode of mania.” It is not immediately obvious why this was so clear, as there is virtually no evidence indicating this. One single study13 (N=19) found bupropion to be less likely to induce a switch than desipramine. The final results of Post, above, are still pending, but it appears evident that if one has decided to accept the myth that antidepressants induce mania, there is no reason to believe bupropion is any less likely to do this.

The accumulated data in the field strongly suggest that the real risk in the treatment of bipolar depression is ineffectiveness, not mania.

-------------
2 Prien RF. Klett CJ. Caffey EM Jr. Lithium carbonate and imipramine in prevention of affective episodes. A comparison in recurrent affective illness. Arch Gen Psych 29(3):420-5, 1973 Sep.

3 Prien RF. Kupfer DJ. Mansky PA. Small JG. Tuason VB. Voss CB. Johnson WE. Drug therapy in the prevention of recurrences in unipolar and bipolar affective disorders. Report of the NIMH Collaborative Study Group comparing lithium carbonate, imipramine, and a lithium carbonate-imipramine combination. Arch Gen Psych 41(11):1096-104, 1984 Nov.

4 Boerlin HL. Gitlin MJ. Zoellner LA. Hammen CL. Bipolar depression and antidepressant-induced mania: a naturalistic study. J Clinical Psychiatry. 59(7):374-9, 1998 Jul.

5 Wehr TA. Goodwin FK. Rapid cycling in manic-depressives induced by tricyclic antidepressants. Arch Gen Psychiatry. 36(5):555-9, 1979 May.

6 Jann MW. Bitar AH. Rao A. Lithium prophylaxis of tricyclic-antidepressant-induced mania in bipolar patients. Am J Psychiatry. 139(5):683-4, 1982 May.

7 Amsterdam JD. Garcia-Espana F. Fawcett J. Quitkin FM. Reimherr FW. Rosenbaum JF. Schweizer E. Beasley C. Efficacy and safety of fluoxetine in treating bipolar II major depressive episode. Journal of Clinical Psychopharmacology. 18(6):435-40, 1998 Dec.

8 Peet M. Induction of mania with selective serotonin re-uptake inhibitors and tricyclic antidepressants. British J Psychiatry. 164(4):549-50, 1994 Apr.

9 Nemeroff CB, Evans DL, Gyulai L, Sachs GS, Bowden CL, Gergel IP et al. Double-blind, placebo-controlled comparison of imipramine and paroxetine in the treatment of bipolar depression. Am J Psychiatry 2001; 158:906-12.

10 Post RM. Altshuler LL. Frye MA. Suppes T. Rush AJ. Keck PE Jr. McElroy SL. Denicoff KD. Leverich GS. Kupka R. Nolen WA. Rate of switch in bipolar patients prospectively treated with second-generation antidepressants as augmentation to mood stabilizers. [Clinical Trial. Journal Article. Randomized Controlled Trial] Bipolar Disorders. 3(5):259-65, 2001 Oct.

11 Post RM. Leverich GS. Altshuler LL. Frye MA. Suppes TM. Keck PE Jr. McElroy SL. Kupka R. Nolen WA. Grunze H. Walden J. An overview of recent findings of the Stanley Foundation Bipolar Network (Part I). [Journal Article. Review. Review, Tutorial] Bipolar Disorders. 5(5):310-9, 2003 Oct.

12 Sachs GS. Printz DJ. Kahn DA. Carpenter D. Docherty JP. The Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder 2000. Postgraduate Medicine. Spec No:1-104, 2000 Apr.
13 Sachs GS. Lafer B. Stoll AL. Banov M. Thibault AB. Tohen M. Rosenbaum JF. A double-blind trial of bupropion versus desipramine for bipolar depression. J Clin Psych 55(9):391-3, 1994 Sep.

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===== ====== ===== The Last Psychiatrist: Do Cougars Exist?

she appears to be whatever age that puts her out of reach

Does modern society really want hot older women with shirtless, hairless college boys? Time Magazine, always on the cutting edge, says no:

Michael Dunn isn't buying it. The noted psychology researcher at the University of Wales Institute in Cardiff has just released a study that he insists renders the cougar craze a "myth." After examining the age preferences expressed in 22,400 singles ads on popular dating websites in North America, Europe, Australia and Japan, he found no sizable cohort of women seeking younger men.

If that were the simple finding I could shake my head at the ignorance, but that wasn't exactly the conclusion that Dr. Dunn wanted to reach, the one which Time Magazine was fortunately too bored to discuss.

First, his results: when he looked at online dating profiles of 22k people, he found that men of all ages preferred women their age or younger; and women of all ages preferred men their age or older.   Oh. So why is the Discussion section 5 pages long?

It's five pages long because he writes like this:

It would appear that the sex-role reversal lifestyles of the rich and famous as exemplified in the popular press, more specifically pertaining to the tendency for older females to form relationships with younger men, is in no way reflective of the desires evident in the general population. Indeed the toy boy phenomenon may be illusory, being restricted universally to an insignificant elite, as cross-culturally men and women appear to conform to strategies consistent with evolutionary hypotheses.
That's just the first sentence. No one could read that; Time certainly didn't. And so they missed his real "conclusions" and why they're wrong.

II.

The study appears in the journal Evolution and Human Behavior. The whole point of this study is to show that mating is "consistent with evolutionary hypotheses. "

Contrary to the evolutionary perspective on sex differences in age preferences are theorists who posit that any sex differences that do exist do so primarily due to both sexes conforming to sociocultural expectations, economic predicaments or "arbitrary norms." By opposing or at least de-emphasising an adaptive strategies interpretation for these differences such theorists by default if not by direct advocacy subscribe to the view that age cues as attractiveness indices may indeed be more flexible cross-culturally and historically with the capacity to change periodically due to for example changing sociopolitical and/or economic conditions.
If you are reading a story in which the words "adaptive strategies interpretation" are used as a noun, then you are experiencing the linguistic equivalent of The Human Centipede:

One does the talking, everyone else has to eat it.

What he means to say is that there are certain people in this world (e.g. me) who thinks our "mating strategies" aren't guided by evolution but by "sociocultural expectations." I may be all in on evolutionary theory, but not when it comes to human beings mating, not in 2010, not when the media has already decided how I'm going to talk, think, and feel. If evolution isn't driving your decision to drink 10 cans of Diet Coke a day, how could it possibly be driving my choice of sex partner, let alone wife? Birthing hips? Really?

I'll pass

III.

Here's where he study goes wrong.

An opportunistic sample of 22,400 participants' age preferences were collected between November 2008 and ===== ====== ===== The Last Psychiatrist: Doctors May Only Be Paid Once

The ACCME (the people who run CMEs) are asking doctors to comment on their proposal, which is:

Persons paid to create, or present, promotional materialson behalf of commercial interests cannot control the content of accredited continuing medical education on that same content.
In other words, if you're a doctor that is on Abbott's speaker's bureau for Depakote, you would not be allowed to present CME lectures on Depakote's use in bipolar, because even though CMEs are technically free of Pharma influence, you may have a bias because of your prior financial entanglements.

How could anyone be against this proposal?

Here goes...

The logic is important and deceptive. They aren't implying that in order to keep Abbott happy, you'll lie during a CME lecture and say Depakote is more awesome than it is.

They are saying that the bias is deeper, that because Abbott pays you so much, you're going to actually believe Depakote is awesome, and you'll say that during a CME. People will think you're being all scientific, they won't realize that the reason you believe it is because you were paid so much, so often, that you now do believe it.

So the two have to be separated. To keep CMEs pure, speakers can't have been paid by Pharma on a similar topic.

Ok, I have a question: if we do this, why would anyone, ever, choose to do CME lectures over a Pharma talk?

Before you freak out "not all doctors can be bought!" follow the logic here.

You aren't lying-- you actually believe Depakote is awesome.   If you actually believe Depakote is awesome, why wouldn't you only speak for Abbott and never do CMEs? You're being honest, you're saying what you think, what do you care if people are slightly suspiscious because the dinner is sponosred by Abbott? You're telling them what you know to be true.

Take it a step further: what if you believe Depakote is awesome based on science, or your own judgment? And had never been paid by Pharma before?

Then you see, the result of this inanity is that anyone who believes, for any reason, Depakote is awesome will have to choose between giving a few CMEs a year for less money, or lots of Pharma programs for more money.

I observe that there's no prohibition on receiveing NIH money and giving CMEs, because obviously there are no biases at the NIH.

Look, people, if you want to completely ban doctors from ever doing Pharma programs, then let's take the debate there and decide. But if you cannot construct a solid argument for this abolition, then all of this back door, smoke and mirrors protectionism will always follow the law of unintended consequences.

(Another post on the separation of church and state.)

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===== ====== ===== The Last Psychiatrist: Does Media Reporting Of Suicides and Homicides Promote Copycats?

I won't give a detailed answer to this question here (it seems to be no), but there is an article making the reddit rounds now that I need to kill before it becomes another meme (like that other badly reported story about psychiatry.)
The article is from BMJ 2002, called Influences of the Media On Suicide, and it puts its conclusion right at the top:
Reporting and portrayal of suicidal behaviour in the media may have potentially negative influences and facilitate suicidal acts by people exposed to such stimuli. Recent systematic reviews by others and ourselves (unpublished) have found overwhelming evidence for such effects.1 (emphasis mine)
And it offers about 8 references in support. And so now every nut with a microphone can proclaim it loudly: it's the media's fault.
We may want to take a pause and examine these 8 references: none of them offer anything close to "overwhelming evidence." For example:
Reference 1-- the one directly cited for the above statements-- is indicative of the type of "overwhelming evidence" that exists. The study finds that media reporting of suicide is extensive and detailed, but not that there is a clear link to future suicides.

In the summary, the authors use phrases like, "dearth of literature," "evidence is less reliable," "few studies permitting/demonstrating [the link]," "does not demonstrate consistency," "many studies fail to demonstrate" over 11 times in the 3 pages describing the studies.
Despite this, they are sure the link exists-- but they don't actually show the link, they infer a link.    The authors repeat phrases, "it is fair to conclude that the evidence suggests an association [exists]" "tends to suggest," "probably reasonable to regard the association is causal" 13 times in two pages. Under these criteria, it's reasonable to assume the Matrix is real.
Reference 3 (not even linked correctly) is a letter to the editor, describing two cases, where the method of suicide was affected by internet, but not the decision to commit suicide. And the methods were rather weak: one guy took two pills of castor oil, and the other woman tried to drink water. No, I'm not kidding.
Reference 5 is frequently cited in support of media's impact. It supposedly says that a TV show with a Tylenol OD caused more Tylenol ODs: 20% of these suicidal viewers said it influenced their decision to attempt suicide in the first week post broadcast. Maybe-- that 20% is really 6 people. And most had attempted Tylenol OD in the past. Oh, and the authors note that while 17% of the suicidal viewers' choice of Tylenol was influenced by the show, some of them chose not to use it because of the show.
Reference 12 is probably the most cited reference in this field. In 1978 Vienna built a subway, which soon became a popular method of suicide. So the government established guidelines for reporting-- specifically, that the method not be mentioned-- and subways suicides decreased by 80%. Fantastic. Overall suicide rates didn't change, though. Too bad.
So much for the "overwhelming evidence" for a soon to be media soundbite.
The article doesn't make a good case for media influencing the decision to kill yourself, though I'll admit that it may influence the method. And that's where it gets tricky.
It's important to make a distinction between copycat suicides and copycat homicides: more poeple die in the latter, and, let's postulate, they didn't want to die. That has to be part of the calculus in media reporting. Copying suicide by water (instead of pills) is different than copying a 30 person massacre (instead of killing, say, one person.)
But you have to weigh this against the societal costs. The solution offered in these articles is to restrict media reporting. I think we can agree that the media are neither liberal nor conservative, but sensationalists, their bias is titillation. But to allow anyone, especially government, to affect the content of reporting-- literally, the information we are allowed to have-- seems exactly the wrong solution to a problem which may not actually exist. (e.g. I know it seems prurient, but I actually want to know all the details of David Kelly's suicide.)
Not to mention that if you say the media are partly responsible, then you're saying that you're less responsible.
(More on copycat suicides here, and on university suicides/copycats here and here.)

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===== ====== ===== The Last Psychiatrist: Do Narcissists Get Abortions?

Apparently, yes.

I.

I got an email from a reader, Phanatic, which is worth posting in its entirety:

Hi there. You frequently cover topics in your blog that touch upon narcissism in some fashion.

Well, I just read an article in the LA Times that just screams out about it, but doesn't use the word once, because it's supposedly dealing with the abortion debate, talking to men who have regrets about past abortions their girlfriends had.

Here's an excerpt. This guy takes the narcissism cookie:

Chris Aubert, a Houston lawyer, felt only indifference in 1985 when a girlfriend told him she was pregnant and planned on an abortion. When she asked if he wanted to come to the clinic, he said he couldn't; he played softball on Saturdays. He stuck a check for $200 in her door and never talked to her again.

Aubert, 50, was equally untroubled when another girlfriend had an abortion in 1991. "It was a complete irrelevancy," he said. But years later, Aubert felt a rising sense of unease. He and his wife were cooing at an ultrasound of their first baby when it struck him -- "from the depths of my belly," he said -- that abortion was wrong.

Aubert has since converted to Catholicism. He and his wife have five children, and they sometimes protest in front of abortion clinics. Every now and then, though, Aubert wonders: What if his first girlfriend had not aborted? How would his life look different?

He might have endured a loveless marriage and, perhaps, a sad divorce. He might have been saddled with child support as he tried to build his legal practice. He might never have met his wife. Their children -- Christine, Kyle, Roch, Paul, Vance -- might not exist.

"I wouldn't have the blessings I have now," Aubert said. So in a way, he said, the two abortions may have cleared his path to future happiness.

"That's an intellectual debate I have with myself," he said. "I struggle with it."

In the end, Aubert says his moral objection to abortion always wins. If he could go back in time, he would try to save the babies.

But would his long-ago girlfriends agree? Or might they also consider the abortions a choice that set them on a better path?

Aubert looks startled. "I never really thought about it for the woman," he says slowly.

Yeesh. He's 23, he gets a girl pregnant, and he slips $200 under her door, goes and plays softball, and never speaks to her again. And to this day, the regret wasn't that he was a self-centered asshole who slipped $200 under her door, went and played softball, and never spoke to her again, it's that she aborted the child. Never really thought about it from her point of view.

I say again, yeesh.

II.

Well, it's probably worse than that.

Consider that the problem here isn't his changing stance on abortion, but rather that he was so self-absorbed he couldn't even consider the woman's perspective. That's narcissism: you're the main character, everyone else is supporting cast. They don't get backstories, or motivation. They're just foils.

And in 17 years, it still never occurred to him to think about her feelings on that day.

Bad enough, but observe that he is so self-absorbed, even today, that he didn't even consider that he would appear foolish in a newspaper article. In the LA Times!

He knows she's going to ask him questions about abortion, about a "woman's right to choose"-- he doesn't even take a minute to come up with a few soundbites about that? No prepared responses just in case they ask him, say, the obvious?

No. Because that's not how he thinks. He probably thought, great! The LA Times! Finally the recognition I deserve! Never once considering that the article might be a sneak attack on the pro-life movement using him as a straw man. Narcissism does not allow you to consider that things-- good or bad-- are about something else other than you. I'm not saying the article was a sneak attack-- merely that he did not consider it might be. And he was thus very unprepared. The guy is a lawyer-- his job is to be ready for precisely this sort of thing.

Did he consider that the article might reflect badly on his practice? That his name would be googled and then blogged by, for example, nut psychiatrists in California?

No. He could only see the potential of an article from the context of his identity, which therefore meant it would be wholly aggrandizing. That in showing how bad he was, he can signal how good he is.

Remember, narcissism is: getting people to believe your backstory.

III.

But let's ask a different question. Chris Aubert is a Houston lawyer. I'm sure the Rolodex at the LA Times is extensive, but exactly why does it contain a Houston lawyer? Of all the men who've "had" abortions, why him? Random?

Turns out Mr. Aubert has been profiled before: born Jewish, abortions in 1985 and 1991, converted to Catholicism in 1997 after he married his Catholic wife, etc. He even wrote an article about it.

Clearly, then, he was selected. The LA Times writer came prepared, she already knew what he was going to say. That's why she picked him. Do you understand? She wasn't writing a story about her discoveries about this issue, she was writing a story about what she already believes, and he fit that story.

In the article Aubert's article From Jewish to Catholic By Way Of Abortion, the word "she" appears only 8 times-- only 3 in reference to his former girlfriend. The word "woman" appears 3 times. "Her" 6 times.   In 9 pages. Get the picture? "I" appears 201 times. "My" 83 times.

I doubt the LA Times reporter was sitting there counting, but she must have thought: no way has this guy ever given a moment's thought to women-- or anyone but himself.

It is why also why his picture isn't at the top of the LA Times article-- he looks too normal. For the photo, they use a guy with, well, a mullet. I'm not trying to criticize the guy(s), I'm just showing you how you construct an article you want to convey a hidden message: anti-abortion guys are clueless.

So didn't he think to investigate the journalist? A Google search? Just to see what bias she might have?

I did-- the right wing crowd has a lot of problems with what they perceive to be her pro-choice bias. I'm not saying she has a bias or doesn't, but wouldn't you at least want to be better prepared for the interview?

No. Not because of a lack of intelligence, but because it is impossible for him to think any other way. Forget about considering whether his beliefs are wrong, he can't conceive of other beliefs except as prelude to his own. The LA Times' writers exist only in relationship to him, as a means of disseminating his own opinions. They do not exist by themselves, they don't have an agenda outside of him. They can't hurt him.

Unfortunately, they did.

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===== ====== ===== The Last Psychiatrist: Don Draper Voted "Most Influential Man"

The most important thing to understand is this: Don Draper does not exist.

AskMen selects him "Most Influential Man"; for context, last year was Obama.

On just about every level, the show's protagonist is a jaw-dropping example of what so many men try -- and often fail -- to be.

That would be a man, a real man; not a man-boy

...[who are] are much more boy than they are man, obsessed as they are with fast food, video games and bodily functions. If the mainstream media is awash with representations of perpetually pubescent males, then Don Draper's masterful manhood stands in stark contrast.
II.

One might think it ironic that this brand of retro-masculinity is being honored by a site that that itself caters specifically to "perpetually pubescent males." It's no accident, it's website bait, like putting pictures of girls in bikinis. The type of person who wants to be Don Draper is squarely in AskMen's target demo. If you're watching it, it's for you.

I understand the appeal, why someone would want to be Don Draper. But I'm going to try and explain why you shouldn't. This post isn't for everyone: you know who you are.

III.

Don Draper is a narcissist. That's not an assessment, it's the premise of the show. The definition of a narcissist is one who creates an identity and prizes it above all other things, every moment of existence is spent perpetuating that identity, trying to get everyone to believe it. That's Don Draper. The show gives him an interesting back story, but the key element is that the man at the ad agency called Don Draper is a constructed fake identity, one which he protects zealously. Nothing else carries that much importance.
And like all narcissists, Draper isn't pretending; he's convinced himself that's who he is. He often sabotages his job, health, and his relationships with only transient anxiety; but when his real/original identity is threatened to be exposed, he almost goes bananas.

The ultimate goal of narcissism is not just to get everyone to accept the identity, but to get everyone to perpetuate it. He wants to be a brand. He wins when people confirm the brand even when he's not around, like when someone on a train says to another, "Dell makes the clearest flat panel monitors around." That guy's reinforcing the Dell brand. Never mind they are all made by Samsung.

Neither does narcissism care about being liked, only about being branded. You can hate the taste of Fiji water, as long as you concede that that horrible taste is the result of the water being too pure and from Fiji. The fact that you hate it is an advertisement itself; it supports the brand as something that the kind of person you are wouldn't like.

On the show, the office staff regularly discuss Draper's exploits and characteristics, always in the same way. People may like or hate those characteristics, but no one disputes the characteristics. Campbell, indeed, hates him for these characteristics.

IV.

Don Draper (the character) wants everyone to believe his persona. Well, it worked; not only do the readers of AskMen believe it, they want to emulate it.

You think it's passive on his part; he's hyper cool, and you want to be like him. Wrong. He's trying to con you into thinking that. He's voted Most Influential not because he has enduring qualities worth being influenced by, but because he is trying to influence you.

"You're getting way too abstract. I just like how cool he is, that's all." This is what I'm trying to tell you. He's not cool, he's pretending to be cool.

V.

"I don't want to be Don Draper, just the old time masculinity he represents." Don Draper doesn't represent that, he's faking it. Look at the show: how come in a show set in those "old times," there aren't any other "real men?"

"Ok, fine, but he is masculine, strong, suave..." You're saying something you don't even believe. If you met Don Draper at the company picnic, would you think he was a real man? Would you want to emulate him? Would you want to take over his body and life?

"Well, certain characteristics..." Now you're almost there. You want to be an a la carte version of Don Draper. You want to pick and choose the good parts. When he's voted Most Influential, they mean only the iceman, suave, sly, creative, "masculine" Don Draper. That's not a person, that's a brand image. If you hired an engineer from Dell because you like how they built the monitors, you hired the wrong guy.

VI.

"But I want to be a ladies man like Don Draper. Back then it was easier, because affairs were more acceptable."

No they weren't. Leaving aside morality, cheating on your wife means that you haven't fully connected to her, or have lost some of that connection. You don't have to be Don Draper to pull that off. "Well, I want to be as suave as he is, I want to pick up girls like he can." It's the same disconnectedness. You could do it, too, then you'll lose the ability to be deeply connected to someone. You can't do both simultaneously.

Consider a guy in 2009 who says he can't meet women in bars. The biggest mistake guys make when trying to meet women is being overzealous, overinvested. They are unable to differentiate a one-night-stand from a full relationship.   They approach both in the same way. When you're trying to get laid, you can't be trying to show her your soul, and you can't be trying to see hers. It has to be light, fun. The "pick-up tricks" work because they delay the guy from doing what comes naturally, which is being stupid, dropping all 52 of his cards in her lap and saying, "see?! I'm worth it, I think!"

This is why many men who actually get what they think they wanted are still unsatisfied. They meet a hot girl and it turns into a relationship, and they're upset they can't get one night stands. But if they got a one night stand, they'd be upset they couldn't convert it to a relationship (and of course it would be her fault for being a slut, not knowing what she wants, etc.) You can't have it both ways.

Here's how the logic disintegrates: if you're at a bar and see a woman with a tattoo on her tailbone and big hoop earrings, we can all agree, given the right circumstances, she'd probably be up for a one night stand. "Yeah, but she only wants a guy who X---" Maybe, but she'd probably settle for you. "I don't want her to settle for me, I want her to want me." Then you don't really want a one night stand, do you?

She already knows all of this. Just as you think you can tell those are implants, she's has you sized up from 100 paces.

Here's how you succeed: you have to have confidence in yourself, while simultaneously accepting that it could just as easily have been some other guy. If you're not comfortable with that, get out of the bar.

VII.

"But it's the whole idea of Don Draper-- that kind of man, living in that kind of time, where men were men... it was more acceptable to have affairs, drink all day... The old days, men could act like men, even if they were flawed."

Draper can seduce women easily because he has both confidence and also lives, perpetually, in that state of emotional disconnectedness that let a girl know you're not going to get all mushy on her. But that means he also doesn't connect with his wife, nor she with him; that's why the affairs "aren't a big deal." It has nothing to do with the year being 1960. It's just a bad marriage.

You should note that his disconnectedness doesn't make his wife less connected to him (though it doesn't help.) His disconnectedness lead him to marry a woman who was not likely to be able to fully connect to him. Many times, you get only the relationship you're ready for.

This isn't unique to Draper. Look at Campbell. He can cheat on his wife with almost no guilt because he's disconnected from her; but of course she is just as disconnected from him. She doesn't love him, she needs him as a supporting cast in her "perfect wife and mother" movie.

The show doesn't depict a "different time;" it depicts a (somewhat improbable) scenario where everyone in a 200 mile radius is a narcissist.

VIII.

Shakespeare created a lifelike, realistic character named Hamlet. Every actor who plays him, from Richard Burton to Mel Gibson, reinterprets Hamlet differently.

What no one does is try to emulate Richard Burton playing Hamlet. You're not playing a character, you're pretending to be someone else.

In the 2009 movie Star Trek, Captain Kirk was played by Chris Pine. But Pine wasn't playing only Captain Kirk, he was playing William Shatner playing Captain Kirk, i.e. using Shatner's same staccato delivery and other mannerisms. Any accolades Chris Pine gets-- "he was great in Star Trek!" refer to his ability to imitate William Shatner, not be Captain Kirk.

When you say you want to be like Draper what you are saying is you want to be the person Draper is pretending to be in a specific context. That's not real. Given that Don Draper is a character acted by Jon Hamm, then you're saying you want to be what an actor is pretending to be pretending to be. If you even try this for Halloween, they're going to lock you up in a lunatic asylum.

IX.

What you want, really, isn't to be Don Draper. What you want is to live in Draper's world: where it is almost acceptable to have affairs; where you can drink all day and not get drunk; where you can say whatever is on your mind and not have it offend people; where creative men have some outlet for their ideas, and at least get paid really well instead. Where you can eat any kind of food you want and not get fat. Where you can act like you want to act, act like what you think a man acts like, and people will admire you.

In other words, what you want is to be the main character in your own movie.

part 2 soon

------------------

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===== ====== ===== The Last Psychiatrist: What The Miss USA Pageant Says About Us

i am completely disgusted that she would do this for free

I.

And that's why it is ridiculously obvious that when the Miss USA Organization, co-owned by Trump and NBC television, released a racy video lingerie photo shoot of this year's contestants... the sole purpose was to pump up the ratings for this Sunday night's telecast of the 2010 pageant on NBC.

No.

This past pageant got 6.6M, which is the same as last year.

You may be tempted to think that these scandals are blown up in the media in order to boost ratings for the pageant. Yet while everyone knows about the controversies, you can't find one person (other than me) who actually watched the pageant. The marketing has all failed, from Vanessa Williams to Carrie Prejean. Why would they think seeing half naked women in lingerie would entice me to want to watch them fully clothed? Whoops?

IIa.

The photos seemed designed to generate controversy and buzz about the pageant, TODAY's Matt Lauer suggested to pageant president Paula Shugart. "Yes, to some degree it's marketing," Shugart admitted

Wrongolongoria. The controversy isn't to get viewers to watch the Pageant, the controversy is to get viewers to watch the Today Show.

Shows don't operate on their own, they're soldiers in a standing army. Miss USA is run by the Miss Universe Organization, owned by Donald Trump and NBC Universal, which is co-owned by GE and Vivendi. That means the Miss USA pageant can be enjoyed as a loss leader for MSNBC, NBC, USA Network, Bravo, A&E, Hulu, Activision/Blizzard, and Universal Studios.

And rival media is free to capitalize on it if they want. Oh, is she Muslim? Then off to Fox News and Glen Beck and etc. You think CBS is talking about it because they want to boost NBC's ratings?

Whenever someone talks about a television's show's ratings as if they have valuable information, punch them in the mouth.

IIb.

Small aside: if the game is eyeballs, then it becomes less relevant that they get the facts straight once you are watching; only that you watch.

Is this what the Miss USA represents? It used to be all -American girls, the leaders of the future. These are the leaders of the future?

If you're watching this Fahrenheit 500 deliver the business news from a bar, you're probably not worried about accuracy. Why do I suddenly want a drink and a plane ticket?

III.

CBS News, unaffiliated with the pageant but hey, it's news, right? gets to ask, "Are Rima Fakih's Sexy Shots [of her in the stripping contest] Any Worse Than The Lingerie Photos?"

The answer, obviously, is yes, they are worse, they are much worse, and by worse I mean much better. If I have only one click left, I wanna see the stripper pole. Lingerie? What is this, the set of Falcon Crest? Bring on the pole.

"Americans are a puritanical lot that can't handle sexuality." Oh, no, they handle it just fine, otherwise it wouldn't be everywhere. They just can't handle it when they're with other people.

When you're by yourself and the sex scene in a rated R movie comes on, do you change the channel? "It seems wrong to watch the expression on her face change as she mounts him. I choose to turn away."

But with every passing year of marriage those scenes frustrate, you try to avoid them. Not when you're Alone, of course, but when you're watching with your spouse: you worry it is reminding them how inadequate you have become.

It happens also when you're with people you're not intimate with. Are they watching how you are watching it? If you're too interested, will they think you're a pervert, and if you appear bored, will they think you're a prude? So there's dead silence as everyone in the room pretends they're not pretending.

The word for all of this is shame.

It's perfectly normal to feel this way. But you chose this world, this is the one you wanted. What kind of a world is it where we want sexuality in everything, have normalized sexuality in everything, but are ashamed to be caught looking at it?

A world that prefers to be alone, of course.

IV.

A quick word on the homosexualization of public sexuality, or, what's up with all the naked guys in ads and movies nowadays? Is everyone gay? No. Otherwise it wouldn't work.

When a guy gets caught watching a naked girl in a movie, he's got some pretending or explaining to do. When a guy gets caught looking at a naked guy in a movie, he still gets the signifier of sexuality to use any way he wants, but without the shame. That the ladies might like it is an added plus.

Son of a bitch... Posh Spice is smoking hot

V.

There's a simple reason why the stripping pics are "worse" than the lingerie pics: she was told to pose in lingerie; she chose to strip on her own.

If there is one thing that makes Americans-- or at least the media, ===== ====== ===== The Last Psychiatrist: Don't Hate Her Because She's Successful

the first thing you noticed is her great outfit
and the first thing I noticed is she's covering her wedding ring
this is why you are anxious and I am Alone

Today in the United States and the developed world, women are better off than ever before. But the blunt truth is that men still run the world...

It is time for us to face the fact that our revolution has stalled. A truly equal world would be one where women ran half of our countries and companies and men ran half of our homes. The laws of economics and many studies of diversity tell us that if we tapped the entire pool of human resources and talent, our performance would improve.

I.

Sheryl Sandberg is the future ex-COO of Facebook, and while that sounds like enough of a resume to speak on women in the workplace, note that her advice on how to get ahead appears in Time Magazine. Oh, you thought that Sandberg's book is news worthy in itself, how could you not do a story on this magnificence? No, this is a setup, the Time Magazine demo is never going to be COO of anything, as evidenced by the fact that they read Time Magazine. Much more importantly, they are not raising daughters who are going to be COO of anything. So why is this here?

The first level breakdown is that this is what Time readers want, they want a warm glow and to be reassured that the reason they're stuck living in Central Time is sexism. This demo likes to see a smart, pretty woman succeed in a man's world, as long as "pretty" isn't too pretty but "wearing a great outfit" and that man's world isn't overly manly, like IBM or General Dynamics, yawn, but an aspirational, Aeron chair "creative" place that doesn't involve calculus or yelling, somewhere they suspect they could have worked had it not been for sexism and biological clocks. We all know Pinterest is for idiots. Hence Facebook.

II.

If you are still suspicious that Sandberg's appearance in Time has nothing to do with her book or with women becoming COOs but is about something else, look through the newsstand for the other magazine in which Sandberg is prominently featured: Cosmo.

the first thing you noticed is her great outfit
and the first thing I noticed is she's showing her wedding ring

This is the mag she felt compelled to guest edit, an issue that also has "The Money, The Man, The Baby: Get What You Want," by future Labor Secretary Kim Kardashian. No one reads Cosmo to become a COO, no one who reads Cosmo could become a COO, because-- and I'm just guessing-- they think the the secret formula for success is Dream Job + The Right Partner + Great Wardrobe = Yes I Can! Well, you ===== ====== ===== The Last Psychiatrist: Don't Settle For The Man You Want

I stopped reading The Atlantic when I wanted to stop cutting

Lori Gottlieb, in The Atlantic, writes Marry Him!, and describes a problem so pervasive and urgent it's hard to imagine Obama hasn't cleared his desk: what's an "independent," "feminist," "heterosexual" 40-something "woman" with a sperm-donor child to do when she can't find a man to marry her?

My advice is this: Settle! That's right. Don't worry about passion or intense connection. Don't nix a guy based on his annoying habit of yelling "Bravo!" in movie theaters. Overlook his halitosis or abysmal sense of aesthetics. Because if you want to have the infrastructure in place to have a family, settling is the way to go.

Oh, that Lori Gottlieb, she's a kidder. But she's not kidding.

There's a few ways to go with this, but here's a start: where is she finding all these idiots who yell bravo or have bad breath or poor aesthetics, or is this all the same idiot? If you're 0/3 in a single paragraph, you need to consider the problem is you.

To be fair, my conceptualization of what a good relationship is may be very different from hers. Here's hers:

In my formative years, romance was John Cusack and Ione Skye in Say Anything. But when I think about marriage nowadays, my role models are the television characters Will and Grace, who, though Will was gay and his relationship with Grace was platonic, were one of the most romantic couples I can think of.
Nothing characterizes The Dumbest Generation Of Narcissists In The History Of the World better than using throw away cinema as a template for life. What kind of results did she expect?

She thinks that Will being gay is an unfortunate coincidence, but it is actually the primary thing she wants. She wants a gay man not because she likes them gay, but because gay men aren't real to her, they're props. She wants someone who will see her the way she wants to be seen and fulfill various other roles she has planned for him, leaving herself free to "grow."   It's hard to get that to happen when his Staff Of Unreasoning and Hyperbole is pressed up against her coccyx while she's trying to go to sleep.

II.

That Will & Grace speaks to her is completely by design. The producers tweaked that show specifically for a certain demo, i.e. her.

In its first miserable failure of an incarnation, it was called Ned & Stacey, and it paired Debra Messing with a good looking, heterosexual, womanizing rich guy. Everything else was the same. Here's the opening theme:

Ned: Why Stacey?
Stacey: Why Ned?
Ned: It was business.
Stacey: Strictly business.
Ned: Here's the deal - to get a promotion, I needed a wife.
Stacey: To get a life, I needed his apartment.
Ned: So what the hell, we up and got married.
Stacey: The only thing we have in common? We irritate each other.
Ned: Right! Enjoy the show.

The show lasted one season. No woman could relate to his, no woman would want this, only this. But make the main character gay, and you have a fantasy scenario: materialism and safety, but the emotional freedom to constantly reinvent and reaffirm yourself. The show should have been called, "The Non-Judgmental Dad I Never Had" or simply "Let's Pretend." But I'm not in TV.

III.

There are really two questions: the first is where Lori Gottlieb went so wrong, and the second is why The Atlantic thinks this is a legitimate posture.

A short excursion through Lori Gottlieb's prior life is illustrative.

Her first book, in 2001, is about her experiences growing up to affluent but shallow parents (her description) in Beverly Hills in the 1970s. Pause for effect.

This is what the Amazon blurb says:

In the image-conscious world of 1970s Beverly Hills, 11-year-old Lori knows she's different. Instead of trading clothes and dreaming of teen idols like most of her pre-adolescent friends, Lori prefers reading books, writing in her journal and making up her own creative homework assignments. Chronically disapproving of her parents' shallow lifestyle, she challenges their authority and chafes under their constant demands to curb her frank opinions and act more "ladylike.

Many of you may sympathize. What's a budding intellectual, not to mention future NPR contributor, to do in such a dystopia? Answer: she decides to become anorexic.

Somehow this has been characterized as a struggle with anorexia but you'll have to take my word for it: this is a struggle with anorexia the way Girl, Interrupted was a struggle with inadequate access to healthcare. It's all blamed on her parents, and secondarily on her social group. This is from her website:

"Of course they aren't overweight," Lori told her psychiatrist when asked if she thought the girls at school who diet are overweight. "Didn't I already say they were popular?"

Before you call Bill Cosby, consider that this kid is having a conversation with her psychiatrist. In the 1970s. Whatever you may think about the overpopularization of psychiatry today, there was a very specific demographic of kid that got to talk to a shrink in the 1970s, and that demographic is now in their 40s, unmarried and writing articles for The Atlantic. If you think there's no connection, then Amazon.com suggests you may also enjoy The New Yorker.

IV.

The mistake is to take the writing prowess Lori (now and at age 11) has and assume it mirrors the quality of the ideas. The writing is good (there, I said it) but the idea set is dangerously, catastrophically wrong.

Her next book, Inside The Cult of Kibu, was about her experiences at a failed dot.com. This is the introduction:

In the Spring of 2000, Lori Gottleib was lured away from Stanford Medical School to become the editor-in-chief of Kibu.com.... but after her comically unceremenious "unhiring" three months later...
Work through the timeline. This book was published in 2002. Stick Figure was published in 2000, which means it was written before 2000, i.e. while at Stanford Med. Meanwhile, she's hanging out at Whole Foods (not a joke) and joining Kibu. Then she's fired.   So she hastily put together another book.

You can imagine this is how she dates. No direction, no sense of self, just jumping from one scheme to the next, trying on different identities. She actually laments how, while a med student, she was surrounded by more dot-commers than doctors. At parties they wouldn't think her interesting enough as a med student; but when she signed with Kibu, she

heard myself saying, "I'm on the cutting edge! I'm going to influence an entire generation!" Part of me even believed this.
Your problem is you believed it. My problem is you were right.

V.

A reasonable question might be, what kind of a man is this woman looking for? I defy you to answer this question. She's two books and at least three essays into the topic, and still I have no idea. What I do know, however, is what she's not looking for. That's where her laser focus is pointed.

She titled one essay, "5 Traits In A Mate That Are Not Deal Breakers." Take a moment to ponder the construction of that title. If I wrote an essay, "5 Things You Can Do That Won't Make Me Stab You In The Teeth" how many condoms will I end up using? You might counter with history: she was having trouble with mates before she wrote that essay. True, but you know that the type of person who would think to write an essay like this one reveals herself in other ways as well.

I've never believed that we should stop looking for Mr. Right (we shouldn't!) - but I do think that by changing our rigid idea of who Mr. Right is, we're more likely to find the right Mr. Right. You can't just order up the perfect husband á la carte - I'll take a little of this, a little of that, less of this and more of that. A guy is a package deal, as are we. Recognizing that isn't settling. It's maturity.
I actually had to pull my car over to the side of the road when I read this. This woman is in her 40s. And she has a kid. What the hell did those halcyon hours at Stanford Med do to her?

...having found myself still single at 40, I'd come to an eye-opening realization: Had I known when I was younger what would make me happy in a fulfilling marriage, I would have made very different choices in my dating life.

This woman should have a scarlet "ME" on her shirt. What makes me happy? What do I want? You can't run a relationship this way, you can't run a life this way. But the longer she stays single, the more self-absorbed she becomes, the more she thinks about what she needs and wants.

It's almost unnecessary to list the 5 Things About A Man Lori Is Only Pretending Not To Care About, but here they are anyway: 1. His height. 2. His Match.com profile. 3. His occupation. 4. His age. 5. How he compares to "my type." None of those are jokes.

Indeed. I ended up falling hard for a 5'6", balding, bow-tie-wearing guy I almost didn't e-mail on Match.com. He wasn't who I had in mind, but he was who I wanted to be with. And that, of course, is the thing that matters most.
Indeed, indeed.

VI.

Back to the article. There's absolutely no chance any woman will benefit from reading this article; I'd argue that it would even make her impossible to be in an elevator with.

I referenced Will & Grace, above, but the real star of the article is Sex & The City. This article is written about, and for, Carrie Bradshaw.

It's equally questionable whether Sex and the City's Carrie Bradshaw, who cheated on her kindhearted and generous boyfriend, Aidan, only to end up with the more exciting but self-absorbed Mr. Big, will be better off in the framework of marriage and family. (Some time after the breakup, when Carrie ran into Aidan on the street, he was carrying his infant in a Baby Björn. Can anyone imagine Mr. Big walking around with a Björn?)
She doesn't get it, at all. Are you asking whether I could I imagine a big producer, like the one that Mr. Big is based on, carrying a baby? Sure, why not? Or do you mean a guy like Chris Noth, the actor who plays Mr. Big? He just had one, so yes. Or do you mean...?

Meanwhile, the real Carrie Bradshaw (Candace Bushnell), the actress who plays her, and heck, even the character Carrie Bradshaw, are all in solid relationships exactly opposite to the ones she is looking for.

Mr. Big wouldn't carry a baby because that's the character. If you're looking to hook up with a two-dimensional character, you'll get what you pay for.

VII.

Gottlieb figures that because she's attractive and intelligent, the problem must be her standards are too high or men are threatened by her. Wrong. The problem is she is daring someone to like her. She has a Match.com profile-- fine-- but meanwhile, she publishes articles in major magazines that men are going to read, right? that say things like, "I'm at the age where I'll likely need to settle for someone who is settling for me." How do you like me now! "It's not that I've become jaded to the point that I don't believe in, or even crave, romantic connection. It's that my understanding of it has changed." Who's up for role-play? You think I'm pretty? Bam! Now I have a kid! What do you think of that?

All of this is what an adolescent girl might do, who puts her worst features front and center. She's not sure her best features are going to be good enough, but if you can like her despite the bad ones, then you must be The One. (Never mind that immediate next thought will/should be, "what kind of a loser would like me?")

All of this is a game to elicit a specific response from the man: "oh, baby, those things don't matter to me because I know that's not who you are, I know the real you."

The guy is irrelevant. As long as he delivers his lines, on cue.

VIII.

You may wonder why I am focusing on The Atlantic article and not the book that just came out, Marry Him: The Case For Settling For Mr. Good Enough.   First, I didn't read the book. HA! Take that, required reading list.

More importantly, a book contaminates only its readers, but an article in The Atlantic makes it ok for intelligent people in general to think like this. That makes her wrong ideas dangerous.

You want something uplifting, so here you go: you can never have a good relationship with anyone when your focus is the relationship. There's a human being there who existed well before you got to them, and they weren't built for you or your needs or your parents or your future dreams as an actor. If you want to be happy with someone then your body and mind have to instinctively adapt to their happiness. If you're not ready for this kind of sacrifice, then you're simply not ready.

---

Lori Gottlieb becomes a Therapist: The Cult Of Self-Esteem

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===== ====== ===== The Last Psychiatrist: The Dove Sketches Beauty Scam

the only way to win is not to play

"Dude, are you doing the Dove ad now? That was so April 15th...?" Yes, I realize I missed the meme train, but it's better to be right than part of the debate, especially when there is no debate, this is all a short con inside a 50+ year long con. Remember House Of Games? "It's called a confidence game. Why, because you give me your confidence? No: because I give you mine."

"What's with you and fin-de-Reagan David Mamet?" It's not my fault Dove cast Joe Mantegna as the sketch artist, and anyway if you want to understand the world today, you have to understand how the Dumbest Generation of Narcissists In The History Of The World was educated. See also: 9 1/2 Weeks.

Here's how you run a short con, pay attention:

===== ====== ===== The Last Psychiatrist: Do We Want Neuroimaging In Court?
Or, more specifically: do we want psychiatrists to help judge other people based on pictures even less useful than a Rorschach?

I.

The New Yorker has an article about Kent Kiehl, a researcher who studies psychopaths using neuroimaging techniques; he has a mobile MRI scanner that he takes to prisons.

Brain imaging is rarely used in criminal trials (no reference, but I believe the number is <100.) But when it is used, and it will be more used, it has fairly important effects not just on the case, but on society, e.g.,

Ask any resident about the anatomic correlates of schizophrenia, and they inevitably mention widened sulci-- which isn't actually specific or useful. What most residents don't know is that this "finding" was made real by the trial of John Hinckley Jr: the defense showed that the cortical atrophy and widened sulci was similar to the brains of schizophrenics (and neglected to mention it was similar to findings in a dozen other non-psychotic conditions.) Hinckley was found NGRI, which means hospital, then free; because of this case, we now have "guilty but mentally ill" which means hospital, then jail.
Brain scans were also used in the (failed) attempt at banning violent video games, on the assertion that it caused patterns in the frontal lobe similar to clinically violent adolescents (never mind that "patterns" doesn't mean anything, let alone predict thought.)
We can't execute juveniles anymore (Roper v. Simmons) because of the evidence of ongoing myelination of neurons in the DFC in adolescents as they aged. (Never mind that all the kids in this study were relatively homogeneous anyway, so differences are not to be expected; never mind that this evidence is a long way from saying they lack the ability to take moral responsibility; never mind that, oh, never mind.) Not executing juveniles is a wonderful idea; not executing them because of a lack of myelin is dangerously absurd. So if science discovers their brains are completely mature after all, then what?

These imaging techniques only tell you one story, and it's not even a very good story. They cannot tell you the impact of other forces, including genetics, lifestyle habits, and even the effect of chronic thought patters on brain function or anatomy.

Neither are scans themselves showing what you think they are showing. They are showing something (e.g. glucose utilization) that we interpret as function ("region is activated") which is then used to say, "the amygdala is involved in..." You may as well say Nebraska is involved in.

They are, in essence, a videotape of someone's house while it's raining, from which you are supposed to deduce based on the amount of water collecting on the second floor bedroom window, that he was unable to avoid masturbating at work.

Unfortunately, juries love videotapes.

II.

But more importantly, forensic brain scans represent the worst kind of classism. They say, essentially, that because your brain looks very similar to other brains, then you belong in that class; and you take on their other qualities. They may be appropriate for scientific investigations-- as early clues directing further research, "hey, this is interesting, let's look over here from now on"-- but they have no place in the justice system. I'd argue any association studies have no place in court, especially when they are read backwards ("because he has this, he is this.")

Social scientists are hoping that these anatomic associations to psychopathy will show it to be a mental illness just like any other. Consider the quote from Jean Decety, a professor of social neuroscience at the University of Chicago:

"We still basically work out of a Biblical system of punishment--we don't consider, in most cases, to what extent the offender's actions were intentional or unintentional. But what neuroscience is showing us is that a great many crimes are committed out of compulsion--the offenders couldn't help it. Once that is clear, and science proves it, what will the justice system do?"

Not withstanding that nearly every single proposition in this paragraph is flawed, let's take it to its conclusion: he wants us to consider psychopathy the way we consider, say, bipolar.

Currently, psychopathy is considered an aggravating factor-- if you have it, it's worse for you. This is opposite to bipolar, for example, which can be a mitigating factor. (For example, the coming exemption from execution for "mental illness" won't include psychopathy.) But take a step back: both psychopathy and bipolar are heuristics. They both have about as much and as good anatomical and genetic evidence. In other words, they are formally equivalent. They shouldn't be considered any differently in court. Right? Well, don't get excited: society could just as easily decide that bipolar should become an aggravating factor.

And, importantly, society--psychiatry-- can then change its mind every ten years or so.

Do you want to live in a world where the criminality of an act-- the culpability of a person-- is based essentially on the moral ADHD of a bunch of doctors with third hand understanding of MRI results? Strike that-- on a very select bunch of doctors who purport to speak for these other doctors, who claim to have the greatest grasp of the science, and who claim in complete and absolute seriousness to have the best understanding of the ethical progressivism of society-- better than lawyers or engineers or teachers or priests or anyone else-- ethics which they admit are constantly evolving-- but have thankfully, magically, and conveniently reached their culmination with today. The end of history. 4000 years of ethics, useless; they got it all right with a grant from the NIH and a subscription to The New Yorker.

As if the science really mattered anyway: no matter what those brain scans show, they'd find a way to make them support whatever ethical position is fashionable at the time.

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===== ====== ===== The Last Psychiatrist: Dr. Nasrallah Asks Questions That No One, Including He, Wants Answered

But I'm going to try.
His editorial appears in the journal Current Psychiatry, of which he is the editor. I respectfully disagree.

Why did TV commentators assume the crime was caused by “evil” and “psychopathy,” instead of a medical illness in a young man with many psychiatric manifestations?

Because that’s the logical assumption. The two are not mutually exclusive as implied by the question, and, while "evil" and "psychopathy" are attributions, medical illness requires a basis in pathology. Commentators could not have known whether or not he was medically ill, nor if this illness had anything to do with the violence, but it is definitional that the act was evil.

Reversing the question reveals the fault in logic: why didn’t commentators assume he was mentally ill?  Is that the default assumption in the absence of evidence?

Why do most people assume that a psychotic individual driven by delusions is too “incompetent” or “confused” to plan and carry out a complex series of deadly assaults?

Does anyone assume this? This is a straw man argument. What is really being asked is: why do people assume that if the attack was complex and deadly, it had to be done by an evil mastermind, not a psychotic person? And no one assumes that, either. The question is sleight of hand; it tries to make the issue binary, psychosis vs. evil. The two are not necessarily correlated in either direction (right?)

As above, reverse the question to see the logical flaw: should people assume that complex, deadly attacks are the work of someone who is psychotic? Is psychosis—or, indeed, any mental illness-- a risk factor for extreme violence? That doesn't bode well for a society with "25%" mentally ill, as claimed below.

Why did the mentally ill student receive no follow-up care before the crimes, even though he had received psychiatric treatment?

Perhaps he didn’t want any follow-up care? I know: “but look what happened!” Perhaps we can envision a scenario where a group of experts make a judgment about someone’s dangerousness in the absence of a crime or any concrete evidence (which would allow ordinary legal channels to be used), and then can commit, or restrict this person’s freedom, until they are no longer considered dangerous. We already have this: it’s called Guantanamo. And before you say there’s a difference, let me assure you there is not. Quis custodiet ipsos custodes?

(NB: the context of the quote by Juvenal has an interesting parallel: it is about enforcing morality.   “My friends always tell me, lock her up! Restrain her! But who watches the watchmen? The wife will then start with them...”)

Several issues are being mashed together to extract the favored response, “we need better mental health care.” But it's not valid. If a psychiatric patient commits murder, he goes to jail. If you have good reason to suspect he is about to murder, you commit him. If you feel he is about to murder, but do not have enough evidence to commit him, you contact whomever is necessary (potential targets, etc). And if he is a student, you tell the administration so they can put him on temporary leave.

This is key: it is morally wrong, not to mention illegal, for a psychiatrist to force a person to get treatment he does not want.   But it is entirely legal, and desirable, for a school to insist that a person receive treatment as a necessary condition of returning to the school— if and only if there exists a risk towards others.

Do medical record requirements in the Health Insurance Portability and Accountability Act (HIPAA) protect individual privacy at the expense of public safety if a patient is seriously mentally ill?

No; did any one say they did? If we have reason to suspect imminent risk of harm to self or others, we have multiple avenues/obligations to deal with the situation, confidentiality and privacy be damned. In fact, if psychiatrists simply feel a person is dangerous in the absence of any concrete evidence (direct threats, storing weapons, etc), they can “violate” the patient’s (constitutionally non-existent) right to privacy. They can tell anyone they need to—the school, parents, whomever. What psychiatrists can't do is lock them up or commit them, or force them to take drugs, just based on their “feeling,” without a solid reason. And thank God.

If the university administration had known about the student’s psychiatric disorder, would he have received better treatment and supervision? Or would he have been stigmatized or expelled, whether or not he responded well to medications and counseling?

What, exactly, is meant by “psychiatric disorder?” Schools don’t expel people because they have a mental illness; they expel them because they are dangerous to have on campus. If Cho had been determined to have been dangerous—regardless of the cause, whether it be mental illness, drugs, or Satan’s direct influence, why shouldn’t he be at minimum suspended? (This is very different than being suspended simply for having a mental illness.)

I’ll repeat: it's not discrimination because he has a mental illness; it's discrimination because he is thought to be dangerous, regardless of the reason.

We can’t force him to get treatment, but neither do we have to tolerate his Oddboy, knife wielding nonsense. Being on campus is a privilege, not a right. He either stops, gets treatment, gets a girlfriend, whatever-- or he gets off campus.

How can roommates or teachers receive adequate information to help a mentally ill student or monitor for treatment adherence when HIPAA rules prevent even families from knowing details of mentally ill adults’ diagnosis or treatment?

I’m not sure how many different ways this question is wrong, but six is a fair guess. Why should roommates receive any information? (Or, if things are so bad that they should be receiving information about the person’s mental state, shouldn’t someone else be involved?) Is the dissemination of information for the benefit of the patient, or the protection of everyone else? It's different information. Why is it roommates’, or teachers’, or the schools’ responsibility to help monitor treatment adherence?   If they are “helping” monitor for treatment adherence, are there any repercussions for failing to do this?

This is the creep into a custodial society, the social consciousness flip side of Bush style privacy violations. I know it looks like we want this; I swear to you we don't.

Because the home-to-college transition can be very stressful, should colleges require freshman courses on how to recognize distress and seek help?

My head just detonated. How many credits will this be worth? Is there a test?

Given that schizophrenia, bipolar mania, and psychotic depression often emerge between ages 18 and 25, why have colleges and universities not adopted early screening and intervention?

Because they are colleges, not health maintenance organizations. They don’t screen for pregnancy, STDs, lymphoma… By the way, if the university administration did screen for students’ psychiatric illnesses, are you obligating intervention? If the student refuses, then what? Expulsion?

Are mentally ill persons more dangerous than the general population, or is that perception based on highly dramatized media reports of isolated incidents?

This question should have been asked first. If they are more dangerous, then this debate is really about screening for mental illness as a risk factor for violence. It means that it is ok to expel people for having a mental illness; for more aggressive commitment and supervisory maneuvers; for, well, Kansas v. Hendricks. If you want to go down this road, good luck, I’ll wait for you in Russia. But if they are not necessarily more dangerous, then most of your other questions are moot; we should be treating mental illness, not violence; and we should be dealing with violence as violence, not as the inconvenient symptom of mental illness.

When will health insurance cover brain diseases that manifest as thought disorders or behavioral aberrations, such as schizophrenia or obsessive-compulsive disorder, in parity with brain diseases that manifest as muscle paralysis, such as stroke or multiple sclerosis?

When you can show that they are diseases, not heuristic labels of behaviors. Schizophrenia is easy; what about ADHD? Should it be covered in parity with strokes? Asked another way: given finite resources, are they better allocated towards the treatment of strokes or ADHD? I’m not making a moral judgment, I’m asking about practical outcomes. Do you get the same outcome for your dollar in ADHD as in strokes?

Given that >25% of the U.S. population has a diagnosable and treatable mental disorder, why is our mental health system so fragmented, so inadequate, and so underfunded? And why is there no public outcry to fix it?

Wow.

25% have a diagnosable mental disorder? What definition are we using here? If we are talking about the DSM, then does voyeurism count? (NB: I refuse treatment.)

As evidenced by this editorial, more and more behaviors are classified as, or at least taken as prima facie evidence of, mental disorders.   Following, it is a simple exercise to determine that, in fact, 100% of people have a diagnosable mental disorder. 100% of people have a medical disorder as well, if it includes the disorder “pain.”

It’s sleight of hand. Psychiatry can help these 25% (or 100%), regardless of whether they really have a “disorder” or not. But that doesn’t identify them as necessarily the realm of medicine or psychiatry. This is the "mission creep" of psychiatry-- away from biology, as it claims it relies upon, and towards an instrument of social change. Perhaps it can tackle poverty, globalization, and terrorism next? Furthermore, labeling (not discovering-- labeling) something as a psychiatric disorder is done to imply exclusivity: e.g. if it "was" mental illness, than it wasn’t evil. People will dispute me on this, but re-read this editorial, its point is exactly this distinction.

Finally, as a parent and husband, I have one last question: how can we console the bereaved families of the Virginia Tech students and faculty who suddenly lost a son or daughter, husband or wife in the prime of life?

One way would be to not reduce what happened to the simple result of an untreated illness. “If only he had been in treatment.” Really? Is that all it takes?

For them, improvements in mental health care on our college campuses will come too late.
And for the rest of us, these "improvements" come perhaps too soon.

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===== ====== ===== The Last Psychiatrist: Drug Reps From Congress To Detail Doctors

Oh, my God, I hope you're lying down for this.

I get raped by an email that is not caught by my spam filter, it says that Congress is considering a bill that would create an academic detailing program-- sending in a team of doctors to visit other doctors and give them "unbiased" (scare quotes mine) information about prescription drugs.

I have some questions, of course:

1. This is going to be federally funded: how much will these doctors get paid?

2. Will they be allowed to take docs out to lunch and dinner? If not, is it because it's a waste of time (in which case why does it matter that Pharma does it) or because you don't want to unduly influence the doctors (in which case...?)

3. Where will you get these "academic detailers?" Are they academics? No possibility of bias there, right? Do you really think it was drug reps that made Depakote ubiquitous?

4. Where will this unbiased information come from? You're going to be using published data-- isn't that already free of bias?

5. Seriously, is anyone even a little bit horrified that doctors have so checked out of their own education that Congress has to send in tutors?

5b. Oh, you mean there's so much pressure from marketing that doctors are confused or even manipulated? Then we should probably set up some academic detailers to go teach nutrition to McDonalds customers. I mean, if doctors aren't smart enough to withstand marketing, what chance does anyone else have against a Britney Spears Pepsi ad?

5c. While we're at it, how about academic detailers to Congress? You know, unbiased information on the ethanol mandate and other special interest Kool-Aid they're drinking?

I'll add that for four years, I was hired by the state Medicaid (DHS) as just such an academic detailer. I went around to all the hospitals, especially the state hospitals, giving talks and meeting with docs, trying to reduce the polypharmacy and dosing problem (e.g. three antipsychotics at lower doses, or Haldol 20 + Seroquel 25, etc.)

You want the ironic part? They hired me because the assistant commissioner of DHS was at a Pharma sponsored dinner program I gave, and thought I my talk about the perils of polypharmacy was compelling-- and not Pharma biased.

Oh, and in answer to #1: they paid me more than Pharma did. Tax dollars at work. I'm happy to take the money, of course, but I've previously given my solution for fixing drug costs while simultaneously improving clinical practice. All of this other stuff is useless politics.

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===== ====== ===== The Last Psychiatrist: DSM-V Controversies

If the front page of Psychiatric Times ran a story called DSM-V Controversies, and it contained this picture, what would you think the article would be about?

The picture certainly conjures up the concept of dogma. Maybe you'd think it was about what belongs in the DSM and what does not; what constitutes disease, where does normal behavior stop and pathology begin? Maybe it would be about the larger questions of the appropriateness of basing a science on epidemiology and inference.

And certainly, those are the main controversies in psychiatry. But this article doesn't mention any of those controversies.

No. The entire article is about conflicts of interests, financial ties of the committee members, and setting up rules to prevent the undue influence of "for profit" entities on psychiatry. (As if psychiatry itself wasn't for profit?)

You're thinking, so what?

Be careful. This this isn't an article about financial conflicts on interest in the creation of the DSM; it is an article about the controversies surrounding the DSM, of which this is the only one mentioned.

The difference is subtle, but absolutely vital.   The purpose of the article is to draw your attention away from the existence of the other more important controversies, and focus on the trivial one. It pretends to say, "here is one of the controversies, of which there are many others as well." But by only hammering at the financial, it stops being an example and starts being a patsy.

This is what can be a called a morality play. It doesn't require thought, only feeling and intuition, and elicits strong reactions and emotions. All of this is to distract the masses from the fundamental problems, which require considerable intellectual sophistication and are anyways rarely settled, onto the more immediately rewarding moral opprobrium. Debating about whether a guy who earned $20,000 in Glaxo speaker's fees should be allowed to weigh in on bipolar depression is a far easier and more satisfying argument than "what is bipolar depression?"

You say: surely you aren't suggesting that the authors of the DSM, and even Psychiatric Times, are engaged in a coordinated conspiracy to divert attention from the structural problems of psychiatry and on to meaningless discussions about payoffs and payouts?

No. They're not trying to distract us, they are trying to distract themselves. They're the parents of little Jimmy, protesting to the school administrators that that the words have been changed to "We Wish You A Merry Holiday" so that they don't have to contend with the fact that those carols are the only religious instruction the parents have bothered to provide him.

It is endless Congressional debates about corporate jets and executive pay, so that...

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===== ====== ===== The Last Psychiatrist: Economy: Where We Go From Here

It's not good.

1. I was wrong about the dollar, which continues to fall, but more important than laughing at me is understanding why I was wrong. I could not believe that the Fed, the government, would allow bank closures, would allow the dollar to fall further by waiting too late to cut rates. I was wrong. I should have suspected, though, when in the summer the Fed unanimously agreed not to cut rates, seeing no danger to the economy-- they thought everything would be contained to subprime mortgages.

But any human on this planet knows there is nothing more recessionary than losing your house, except possibly losing your job and your house, or a government policy to kill off all daughters and losing your house.

So I made a bet in common sense, in pride. Wrong. No banks have failed yet, but it is generally assumed Bear Stearns is in real danger of evaporating. You should probably hide your daughters.

2. I was right about GOOG, 520 was the top. Unfortunately, the PE is still 33, and has to fall to about 25 (see #5). So another 20% drop in price is to be expected, though continued (but slower) growth will offset this. See you at 400.

3. Oil is too high. It will fall fast and hard, by which I mean fast and hard. Certainly there are long term demand concerns, which means we'll never see $50 again. But when oil rises 20% but the refiners fall 20% (see VLO), that disconnect means that the oil price isn't related to use, but to speculation. See you at $90.

4. A good rule of thumb I just invented is that people will a spend little more for lattes than they will for gas. I know Brazil is supposed to have a large and delicious crop in 2008, but I don't care. I am drinking more coffee, and the Chinese are going to need more as well, if they're going to keep working to to put lead paint on all their exports. Coffee is cyclical, so wait for a pullback, but see you at 175/lb (that's cents, yo.)

5. You say, well, what about the $200 billion the Fed just lent out ? Great. Where was that money 6 months ago? Here's how it plays out: you have $400B in bad loans. Say that they end up being worth half, so $200B. Banks leverage the money to loan, 5x or 10x, so that $200B loss translates to maybe a $1T that doesn't get lent out, that doesn't make it to the economy. Experts have approximated this to be a fall in GDP of about 1.5% (pessimistically.) Interestingly, as a bad as the housing market collapse is for some homeowners (Inland Empire), it is much worse for the banks/brokers, who (also) have to bear the burden of the losses.

See you June 2009.

(long GOOG call, refiners)

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===== ====== ===== The Last Psychiatrist: ECT Deserves A Press Release

Generally, most doctors think that ECT is a last resort treatment. If the patient failed antidepressants, you could try ECT. The assumption here is that the success rate with ECT would be higher (50%-90% according to studies) than with antidepressants (since they failed them.)

So ECT occupies a special slot in our brains-- stronger, but more dangerous and cumbersome.

Turns out, the 50-90% success is in uncontrolled studies. In controlled studies, it appears that ECT is less effective in treatment resistant patients than in non treatment resistant patients.

Well, duh-- they're the sickest people, so of course ECT will be less effective in them. That's doesn't tell us anything new or useful.

A recent study in the Journal of Clinical Psychiatry, the largest of its kind, finds that prior treatment failure with antidepressants did not predict lower success rates with ECT. Phew.

Well, if that was all there was, it would be a pretty pointless study. And certainly not worthy of press releases. You have to read them, to see how the authors spin the study:

They therefore conclude that given appropriate indications for ECT, "antidepressant medication resistance should not sway the clinician from providing this modality."

Read it again. Just because you failed antidepressants, it doesn't mean you shouldn't try ECT. Huh? I thought that was specifically when you were supposed to use ECT?

"The implication of our study," lead investigator Dr. Keith G. Rasmussen told Reuters Health, "is that even if a depressed patient has not responded to one or more antidepressant medication trials, ECT still has acute success rates as high as for patients who have not had a medication trial before ECT."

That's some might nice sleight of hand. Look how he phrases his comparison: "...ECT still has success rates as high as for those who have not taken meds." See? He's making your baseline clinical experience be all those patients you've put on ECT who have never been on meds, and saying that ECT in the medication resistant will be just as good.

That's the important part, read it again.

He is trying to implant in you the belief that there exists an entire group of patients for whom you used ECT first line, before antidepressants.

---

Oh, I realize he's not doing it intentionally, nor is even conscious he is doing it. But he is doing it nonetheless, because, as with all academia, the business isn't science, science is the business. There's nothing inherently wrong with what he is doing, but we should all be aware of it.

---

It's a product positioning strategy, Marketing 101. You cannot take on a market leader head on, even if your product is "better" because, as the adage goes, "first beats best." Royal Crown cola can't take on Coca Cola.   In order to succeed, you need to position your product as an alternative to the market leader. How? By admitting there is a market leader.

The classic positioning strategy described by Al Ries: "Avis: We're Number 2, We Try Harder" works for Avis because it sets itself up as an alternative to the market leader, as opposed to trying to take on the market leader. In other words, the "We Try Harder" part-- the part everyone assumes is the reason they're going to be better-- is fluff. The real positioning is the first part: it admits it is not number 1, but consequently links it always to the number 1. It forces your mind to create a mental slot for Avis that is as big as the one already occupied by Hertz. It may be #2, but it carries as much weight as a brand in your mind as the #1. And now you can't ever think about Hertz without immediately thinking about Avis.

Antidepressants occupy the "first line" position in the customer's (i.e. doctor's) mind. ECT can't compete directly with them. But Rasmussen positions ECT as an alternative to antidepressants, one of equivalent value. He doesn't say ECT is better than antidepressants-- a point which then becomes a debate-- he says there's no relationship to antidepressants. It's an alternative to antidepressants, equal. Go ahead and try, you have nothing to lose, they're all the same.

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===== ====== ===== The Last Psychiatrist: Either Conservatives Are Cowards Or Liberals Are...
I.

A news story, talked about ad nauseam, concerning a study in Science that no one will bother to read.

Subjects-- liberals and conservatives-- are shown random pictures of scary stuff (spider on a person's face) interspersed between photos of neutral stuff (bunnies.)   Conservatives exhibit much more fear (e.g. startle response, skin response) than liberals.

In case the political implications of this study are not obvious, these are the titles of the news reports about the study:

Science News: The Politics of Fear
Slate: Republicans Are From Mars, Liberals Are From Venus
Scientific American: Are you more likely to be politically left or right if you scare easily?
Freakonomics blog: Don't scream, you'll give your ideals away

Etc. The message is clear: conservatives get scared more easily than liberals.

Right? That's what the titles say-- I'm not off base here, right? There's no other possible way to interpret them?

II.

The methodology is fine-- but the interpretation is so demonstrably flawed that they are actually interpreting the results backwards.

Here's the most important line of all-- found only in the SA article-- in the second to last paragraph, of course:

People who leaned more politically left didn't respond any differently to those [scary] images than they did to pictures of a bowl of fruit, a rabbit or a happy child.

Really? Spider on face vs. happy child? No difference?

That extra bit of info doesn't even appear in the Science News story-- or anywhere else, for that matter.

The graph shows that liberals and conservatives have a trivial skin response to neutral pictures, and liberals show no difference in response when confronted with a scary photo.

So the actual finding isn't that conservatives are fearful; it's that liberals seem not to exhibit much response to scary photos.

III.

But it's actually a little worse than that.

The typical use for such tests of startle and fear aren't to see how scared people are, they are used specifically to find out how scared people aren't. For example, they are used to evaluate psychopathy, and the results are the same as here-- psychopaths have decreased responses, compared to normal people, to aversive photos.

So which is it? Are conservatives fearful, or are liberals psychopaths?

I'm not picking sides in the debate, but I am pointing out how this study missed the actual result-- liberals are less fearful than would be expected-- and then the study was publicized in the media with an entirely backwards inference, that conservatives scare easily.

But it sounds like science, conducted by scientists; it's published in Science, and then publicized in Scientific American. It must be true.

(more)

What's the link? Perhaps physiologic responses are genetic, and influence your future political persuasion; or your political persuasion/upbringing affects how you respond to threats. Or, this insane idea:

Alternatively, political attitudes and varying physiologicalresponses to threat may both derive from neural activity patterns,perhaps those surrounding the amygdala.

In other words, they're both genetic, and located in the pineal gland. Sorry, I meant amygdala.

The idea is so empty, so vacuous, that it barely can be imagined, let alone written down in the pages of Science. It is entirely analogous to this: brunettes are biologically programmed to want sex at certain times, and they seem to be located in the area surrounding Kansas.

I should point out that while the journal is called Science, the authors of this paper are actually political scientists. Not that there's anything wrong with that.

You can blame the general news media for being lazy and/or retarded. But the authors of the study are directly to blame for purposely skewing the results to the conclusion that conservatives are cowards.

"How so?" you ask. "I read the article and it is very neutral, it even says you're not supposed to make that inference."

Wrong. When you write something, you must be aware of how people will read it. Since it is very obvious how this study will be taken, it is the authors' responsibility to prevent it from happening. Notice that they did not, anywhere write the equally plausible possibility that liberals inexplicably exhibit much less fear than would be expected-- let alone that they score high on a measure of psychopathy. There is nothing in the study that favors one interpretation over the other. And to only focus on one, even if it is to say, "now, we're not saying conservatives are cowards," is leading. Misleading. On purpose.

---

I tried to find some of the pics this study used, this is one NPR had:

What strikes me about the "fear content" of this photo is that it is not immediate. Your eyes are drawn to her eyes and her mouth, and then later you see the spider that gives you the ugh feeling. I wonder-- and I'd need to see the other photos-- if all of them do not require such a two step perception, and if that isn't the basis for the difference in fear responses. (e.g. uncanny.)   Is it the "wrongness" of the pic-- spiders aren't supposed to be that big, or on someone's face? Or is it the (seeming) powerlessness of it--all she can do is scream? How would the reactions be different if the woman was smiling?
===== ====== ===== The Last Psychiatrist: Election 2008

Remember the good old days of 2004? When political debate was suitable for yelling out open car windows? "Bush lied! And he's a cowboy!" "Kerry flip flops! And he's French!" That was awesome.

This time around, instead of repeating empty, meaningless soundbites that we steal from various media sources, let's dispense with the pretense that we thought anything through, and simply yell out the sources themselves.

"CNBC at 12:30 Tuesday. I don't remember most of it, but he got it from Rush Limbaugh."

"That's stupid, because I caught the last nine seconds of a contrasting position on Lou Dobbs at 8p on Wednesday. That's prime time."

"My friend said XM said that All Things Considered said Dobbs was a fool, and ATC is certainly more intellectual than the show you didn't watch, so I am ahead."

He boots up his Mac. "Except The New Yorker had a three page story on the election that I therefore didn't need to read, so I own you."

"Oh, please, the friggin New Yorker. I read Daily Kos."

"The Daily Kos can blow me."

Pause.

"That's it?"

"Just saying." He orders another decaf mocha. "Besides, Time said bloggers are monkeys with one hand down their pants."

"The crawl on CNN said Time readership is down, and masturbating primates have determined six of the last three elections. The crawl is where all the good stuff is."

"You wish. That crawl is as compelling as a Soulja Boy acoustic set. Besides, the anchor at CBS made fun of CNN. Anchor beats crawl."

"But didn't the CBS anchor steal his quotes from CNBC?"

"Yes, who in turn quoted Rush--"

"--who was responding to something from The Daily Show!" He tears open a Splenda.    "Wait, does all political discourse in this country originate with Rush Limbaugh and Jon Stewart?"

"Sadly, yes."

Pause. He googles Juno and iphone.

"I wonder why that is?'

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===== ====== ===== The Last Psychiatrist: Election 2008: "What Patriotism Means To Me" The differences in the essays can be summarized by the differences in the use of personal pronouns:

I/me/my: McCain 3 Obama: 25

McCain makes appeals to abstract notions and higher concepts, and subordinates the individual to the greater. Obama places at the top the society of individuals and grounds abstract notions to their immediate and real world analogs.

McCain goes for the abstract

Patriotism is ... putting the country first, before party or personal ambition, before anything. It is the willing acceptance of Americans...to try to make a nation in which all people share in the promise and responsibilities of freedom.

Obama's goes for the personal and the interpersonal, and grounds abstractions in an individual reality:

...patriotism in my mind--not just a love of America in the abstract, but a very particular love for, and faith in, one another as Americans.

...we have the unparalleled freedom to pursue our dreams.

......That is the liberty we defend--the liberty of each of us to follow our dreams.

McCain places the individual at the service of the higher, intangible:

To love one's country is to love one's countrymen.

Obama emphasizes the country is the sum total of the people who made it, and its purpose is to serve those people; abstractions are grounded in reality:

The greatness of our country--its victories in war, its enormous wealth, its scientific and cultural achievements--have resulted from the toil, drive, struggle, restlessness, humor, and quiet heroism of the American people.

McCain makes the reference point a higher, intangible purpose or good, while Obama repeatedly reinforces that the country is the people:

McCain: ...blessed that so many (soldiers) have so often believed in a cause far greater than self-interest, far greater than ourselves.

Obama: ...a willingness to sacrifice for our common good.

McCain asks what will come:

...if we are to be genuine patriots, we must remember also that we are patriots because we love the countrymen we will never know, who will be born after we are gone.

Obama asks what got us here and what it means now:

We can tuck in our children at night and know that they are fed and clothed and safe from harm. We can say and write what we think, without hearing a sudden knock on the door. We can have an idea and start our own businesses without paying a bribe. In America, anything is possible.

I know that stories like mine can happen only in the United States of America.
And, of course, McCain makes explicit that government is supposed to be limited:
where... a love of liberty and self-reliance still check the excesses of both government and man.
...In return, the gift we can give back to our country is a patriotism that requires us to be good citizens in public office or in the community spaces where government is absent.
While Obama makes no distinction between the government or its people:
Those who have signed up to fight for our country in distant lands inspire me, just as I am inspired by those fighting for a better America here at home by teaching in underserved schools, caring for the sick in understaffed hospitals, or promoting more sustainable energy policies in their communities.

...That is the community we strive to build...
It is often said that this election (or recent elections in general) are not really about ideas, but it seems that this election is nothing else but an ideas battle. In many ways they want the same thing, but they differ in the presentation: "energy independence" vs. "sustainable energy policy"; "make sacrifices" vs. "pay their fair share;" etc. That's important because the "why" of a policy, even when the policy is the same, defines our "common good" and influences future policies.

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===== ====== ===== The Last Psychiatrist: Eliot Spitzer and Alexandra Dupre: Don't Choose The Red Pill

What color bikini does Alexandra Dupre have? That's right, you're a pawn.

If you're a guy who has hung out with another guy in the past 12 days, you've had the conversation in which you observe that 1) Alexandra Dupre is hot, but not $5000 an hour hot; 2) that Spitzer is a moron of gigantic proportions, both for his hypocrisy and his now revealed insecurity; 3) only in today's America would getting caught in a criminal act propel you to fame and fortune. She's got the fame already, and I hear that her music downloads-- even if they're just to hear what she sounds like-- are making her rich. And the offers from Hustler, Penthouse, tell-all books, movies. It's all voyeurism, but that's the business she chose.

So the media loves a sexy story, and they milk it for as long as they can, and they found one in Spitzer and Dupre. It's even sexier that she's going to get rich and famous from all this. "Spitzer escort's fame to fuel career prospects" says CNN. But are they reporting that she is getting rich and famous, or causing her to be rich and famous?

By saying she's going to be famous and rich; by saying her website gets a bazillion hits and her songs are being downloaded, they cause it to be true. Dupre may think she's using this opportunity to promote herself, but the media needs her to succeed in order to have someone to talk about. In other words, the media needs her to be a star.

It's not volitional, and it's not conscious. The media isn't saying, "ok, let's make her famous." The "her" comes second, the "famous" is first. The only story they can report is the tantalizing one, even if it isn't objectively accurate.

To illustrate this, let me quote from the above article:

The prostitute identified in court papers as Kristen is an aspiring musician named Ashley Alexandra Dupre. Her identity was only first reported Wednesday, but already her fame is skyrocketing.

Get it? "Kristen" is an alias, her real name is Dupre. Except Alexandra Dupre isn't her real name, either. That's her stage name. Her real name is Ashley Youmans. Actually, that's not completely right, either-- in 2006 she legally changed it to DiPietro, her stepfather's name. But whatever her name is, it isn't Dupre.

But there aren't many articles that will tell you her real name, let alone call her by her real name.

The NYTimes ran a story, "So Much Sex, But What's Fit To Print?" Obviously not her real name; they stick with the ""Kristen," later identified by The Times as Ashley Alexandra Dupre" common in most stories.

Even recent articles that are actually about her, specifically (not Spitzer), like those reporting that she was in a Girls Gone Wild video when she was 17, don't give her name; they call her Ashely Alexandra Dupre. It's worth pointing out that that name didn't even exist when she was 17.

The easy explanation is that the media are a bunch of morons who never bothered to check her real name. That'd be wrong. The correct explanation is that Dupre is the real name for the story they want to tell-- the story isn't about a real girl, it is about a celebrity. Celebrity is created, not documented.

Consider a reverse example: in any news story about the arrests of Snoop Dogg, they always tell you his real name. They revel in it: "--whose real name is Calvin Broadus." That's because the real story is that Snoop isn't who he says he is. The tantalizing part is that he's an imposter-- an ordinary guy, with kids, a wife of a hundred years, and a real (boring) name. That's why he has a TV show about his boring life. And the Osbournes. Etc.

But you're not going to see a reality show of Youmans. Maybe one of Dupre, but not Youmans. The media have requested that you learn a specific reality, one that may or may not mirror reality, that isn't relevant. What matters is that you swallow the Blue Pill, and get so dazzled by the glitter of the reality offered that you don't ask the important question.

---

So the meta-1 level analysis is that the media creates an identity to fit a story; they call her by her stage name because that's who they want to report on, not some New Jersey stonemason's daughter. The media can't even be bothered to research the real story of how she came to be a high class hooker-- they rely almost exclusively on what she wrote on her MySpace page, which she likely made up. On her Alexandra Dupre MySpace page. Get it?

But meta-2 level analysis forces us to consider an expanded question: if they won't tell us her real name or life story, why should we believe anything they say? More specifically, why do we think that the solid part of the story is that Spitzer was exposed, and the incidental part is Dupre? Is it possible that Spitzer's exposure itself is incidental-- that the real story is that he was exposed?

He's been doing this for at least 6 years-- so why now? He's not the only guy in NY politics involved in nonsense-- why him?

I'm pretty sure we will soon learn the answers to those questions.

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===== ====== ===== The Last Psychiatrist: Elizabeth Smart: Hey, You Brought It Up

A post sure to offend everyone, conservatives and liberals, parents and pedophiles.

No one asked me if I wanted to see the docudrama that was Elizabeth Smart, incessantly for almost a year, at the expense of a thousand other more relevant news stories. Fine. Can you at least tell me how it ends?

Elizabeth Smart: "If someone comes up to me and says, 'we prayed for you,' I say, 'thank you very much, we couldn't have done it without everyone's prayers and support.'   Who's "we" and what did you do?
Elizabeth's boyfriend never asks about the abduction. He just ignores 20% of her teen years.

And the mother: "In order to move forward, we have to let the past go."

I think, "why?" I think that these words can't be emotionally connected to Brian Mitchell (the kidnapper.) They must link to Elizabeth. It sounds like forgiveness not to a man for taking their daughter, but to their daughter after finally coming home.

---

So that's my opinion, anyway, uninformed, instinctual, semantic. In my worldview bad people facilitate bad behavior from otherwise neutral people. But what I think isn't really important since I don't have the facts. It's easy for me to speculate that she wanted to go, or at least was ambivalent about escape. Certainly you'd expect Mitchell's defense to suggest this. (1) Fortunately, through the magic of trial, we get to hear all of this evidence, we don't have to speculate.

But wait, hold on a second: where have kidnappers Mitchell and Barzee been for the last five years, since they were caught? In jail, awaiting trial. I'm sorry, let me rattle my GPS-- for some reason it doesn't show that I've been teleported to Russia. How is it that someone can be in jail for five years without a trial?

I'm no liberal-- if execution is what they deserve, let's get on with it. But in no way is it logical or ethical to have non-convicted people in jail for years, no trial in sight. How can anyone justify this? Oh, yeah: psychiatry. They're "not competent to proceed" with trial and are "recommitted" for a period of X days (and renewable indefinitely after that) for treatment to restore their competency.

Now, there are a number of intelligent explanations for why such a system benefits defendants and serves justice, and they are all wrong. (2)

--

And so I am left with the suspicion that this is-- I'll say it-- a stonewall. Or a whitewash, whichever. No one in Salt Lake really wants a trial because no one really wants to know what really happened. And I have to wonder if there wasn't the backest of back room deals to keep the story suppressed, leaving Mitchell in jail forever (but not getting the death penalty) so that the truth need never be told.

I wasn't there. But if my 15 yo daughter was kidnapped at gunpoint and forced to... and they catch the guy, I don't think my response would be the same as Ed Smart's: "I just wish he would take a plea deal so this could all be over." I'm not saying he has to pull a Ransom, in which Mel Gibson goes on TV to announce that the ransom money will be instead be paid as a bounty on the heads of the kidnappers--

-- but no anger? None? No desire for any vengeance? I know, I know, he's religious. Me, too.

---

It calls to mind David Chappelle's routine, "How old is 15, really?" in which he observes that if 15 is old enough for a black male to be responsible enough to get the death penalty, it probably is old enough for a white girl to try and escape, or at least not go with your kidnappers to a public party, with burka and beer. Chappelle also observes it's old enough to get peed on by R. Kelley, which isn't relevant here, but funny anyway.

I know, I know, she's only 15-- terrified, Stockholm Syndrome, etc. And I have no right to judge her (in)actions since I am not her, I didn't live her life. Though that brings us back to the black teen: why is fear an acceptable explanation for poor judgment, but anger is not? (Hint: they're both not.)

How old is 15? Well, not old enough to get executed in the U.S. anymore. That's a good thing, but it was decided for the wrong reasons. When Chris Simmons was 17 he broke into Shirley Crook's house, tied and gagged her, and threw her into a river. He did it, but the Supreme Court decided he wasn't accountable for it, only because of his age.

The Supreme Court unilaterally decided that juvenile executions were wrong. Awesome. On the one hand we have the old conservative refrain of an activist judiciary doing whatever it (and France) wants, and on the other the liberal refrain that Congress lacks the balls to simply do the right thing, ever (e.g. make a law banning juvenile executions.) I guess that's a conservative refrain as well.

One of the reasons, other than France, that the Court banned juvenile executions is that science has evidence that the adolescent brain is immature, and thus cannot be as accountable as an adult brain. Which makes the France argument not nearly as stupid by comparison.

If you're using the science argument, than the age cutoff is inappropriate, antithetical to science-- period. If science says your brain is immature, then science should be checking each person's brain for immaturity.   It can't generalize and say all 17 year old brains are immature-- you have to check each defendant individually. And if there's no reliable way to check, then it's not clear how you knew they were all immature in the first place. And if its immaturity alone that is important, than that opens the door for a lot of other reasons for immaturity.

You have to be consistent-- either we're doing science, in which case we're looking at a spectrum of immaturity that can occur any time for any number or reasons, or we are not using it because it isn't complete.

Psychiatry really excels at butting in where it is neither wanted nor needed. The moral argument for banning executions is entirely sufficient: "you know what? Shut up. We're not executing kids. Go to hell." But, instead, it turns to make believe science: "there's some evidence that the brains of adolescents are different than adults." Really? So are hormone levels-- is that relevant? Why is it less relevant? And this "brain" you speak of: it's large, no? Which parts are different? Do you actually know what those parts do?

Psychiatry has no business here, but here it is anyway, with its trite observations projected as an evolving science. It is, as Pauli said, "not even wrong." Only psychiatry has the power to be wrong from both political viewpoints.

You know where else you find brain immaturity? Pedophilia. So if having sex with a 15 year old is pedophilia (definitional) we can just generalize that this pedophile, like all pedophiles, has brain immaturity. And so can't be exectuted. Though this defense probably isn't necessary for Mitchell and Barzee, as they likely have both the mental retardation exception and the soon to hit mental illness exemption.

There's some irony that 15 is too young to expect a girl to try and escape, but apparently it is old enough to consent to a polygamous marriage (with court approval, of course.) Oh, I know, polygamay is illegal in Utah. Sure.

---

I get this kind of idiocy from parents, as well, especially concerning marijuana. I say, "I'm not going to let my teens smoke marijuana," and I get these smirks back, "you won't be able to control kids from doing what they're going to do.   They're going to experiment, you won't be able to stop them." Really? It's possible I won't be able to stop them, but is it a foregone conclusion? Are parents completely powerless?

Seems hard to believe that parents have "no" control, but at the same time tell me Elizabeth was entirely under Mitchell's control.

--

More than a few people have observed that when there's a story in the media about a kidnapped girl, she's invariably white. Some, but not a lot, have observed that when it's a kidnapped girl who escapes on her own-- she's black. This seems to support my observation that minority kids are generally considered responsible for their situations (e.g. can be executed; can escape) while white kids aren't (can't be executed, can't escape.) Maybe this isn't a bias, but real: perhaps minorities learn, are raised, observe, whatever, that they have no one to rely on but themselves, their wits. While for whites, there's always a higher authority to appeal to. Or maybe this is the bias that the media has, in reporting these kinds of stories.

--

While we're on the subject: are the Smarts, the cops and the media going to give Richard Ricci's survivors a formal apology? You know, for giving him a stroke?

-----------

(1). It can be suggested that whether or not Elizabeth wanted to go with them is irrelevant, as she is a minor and can't consent. Maybe. Aggravated kidnapping, one of the charges, gets you the death sentence. So you know what? It's relevant.

(2.) "Justice is not served sending to trial people not able to assist in their own defense." That could be a valid reason, except that this is rarely the reason competency evals are done. In other words, competency evals aren't information, they are tactics. As in, "we're not prepared to defend this guy yet, let's postpone for 30 days by... oh, yeah, he seems wacky."

So, yes, if your name is John Dupont, after killing a wrestler in your house you might have some useful information to give to your highly paid lawyer(s) which could help in your defense. However, if your name is, say, Darnell Jones, then it is more likely that your (in)ability to aid in your own defense is irrelevant since your public defender doesn't actually care what you have to say: he's just going to suggest you plead guilty and take time served, whether you're eating feces or communing with thrones, or not. (You want to guess if Mr. Jones is a real person?)

(2b.) Some have argued that lingering incompetently in a pre-trial jail indefinitely is better than lingering in a post-trial death row cellblock. So Mitchell and his lawyer came up with this scheme to stay incompetent. Well, a) why is such a loophole allowed? If society wants the death penalty, there shouldn't be all these back doors to avoiding it. Otherwise, simply get rid of the death penalty (which we should, IMHO.) Have some fortitude, conviction, don't play games with human life. Either we are executing people, or not, no more escape hatches for some and not for others. b) If he did was able to put this scheme together, then he probably isn't incompetent to stand trial, which means the whole thing is a farce; c) if he is "faking," then why isn't the treating psychiatrist, who is responsible for medicating him back to competency, not detecting the faking? Why doesn't he say, "nothing here to treat?" Oh: Mitchell's not been medicated in 5 years. So is the treating psychiatrist in on it, or is the court recommitting him despite the clinical assessment of the psychiatrist?

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===== ====== ===== The Last Psychiatrist: Esmin Green Died Because Only Kings County Hospital Cared

You can read about the case here, but the summary is that a psych patient dies in a Kings County psych ER, and no one notices.

There's indignation and outrage all around, of course, so I won't repeat it here. But I will suggest that the reason it happened has little to do with Kings County.

There's a perfect storm of causes, but three in particular matter most, in ascending order:

1. Racism.

I don't mean "we hate black people" racism. I mean the "multiculturalism worked too well" racism, by which people are now hyperaware of the differences between the races, and so and attribute too much to those differences. "Oh, black people in the ER? Yeah, that happens. They come in when it rains." or: blacks get diagnosed with schizophrenia, whites with bipolar. (Deny it.)

And don't go blaming white doctors; the black doctors I know are no different. Nor are the nurses or social workers.

2. Poverty.

Do you think psych ERs are overcrowded because of the gigantic number of crazy people? Are they overflowing with depressed bond traders? They're overcrowded because of the number of poor people.    I'm not justifying their poverty nor blaming them for it, I am stating as fact that the only option for a person with no resources who doesn't want to sleep in a homeless shelter is psychiatry. Throw in a healthy dose of drug and alcohol addiction, and all roads lead to County.

There's a joke by comedian Greg Giraldo (from memory):

Before Katrina, I wasn't really aware of the extent of poverty in this country. Because so often, poor people look just like black people. So they're easy to miss.
I'll add: reclassify those poor black people as mental health patients, and you have just made an entire social problem disappear.

3. The Welfare State: it's psychiatry.

The sum total of the problem is that psychiatry is expected to be the default social safety net, the bizarre justification being since nothing in psychiatry is entirely the patient's fault, then anything that isn't the patient's fault must belong to psychiatry, including drugs, violence, poverty, etc. The tautology of psychiatry is: if you came to psychiatry for help, you must need psychiatry's help.

Most of these people have few social options. And it helps hide this fact that so many of these people are black-- the expectation of them is less, and minor improvements are considered thunderous successes. These next two sentences are absolutely not lies: 1) we used to be thrilled that a patient actually went to his welfare appointment after discharge. 2) if a male patient threatened to, or did, assault his girlfriend or wife, we were relieved when he agreed not to return home. Problem solved.

But psychiatry takes in these people with no options. And psychiatry can never say no.

So it doesn't say no; it becomes passive-aggressive. For example, it lets you linger in psych units until you decide you want to leave.

While I have no information to defend or indict Kings County-- it sure sounds bad-- but I will say that the failings of city psychiatric hospitals are really the failings of a society that forced them into this position. She died at Kings County because society didn't want her dying anywhere else.

The grey areas of criminal justice; of social work; of morality; of chronicity-- why turn to psychiatry to fill the gaps? A lack of other options does not justify this; psychiatry is not "better than nothing"-- it may be worse than nothing in some cases.

And patch work by psychiatry props up the levees, hides the need for structural reform. Psychiatry is like welfare-- just enough to keep the people from rioting.

It doesn't matter if these problems have a "biological component--" empty words, like we're building a machine.    The problem isn't the guy's biological component of his behavior, the problem is the guy. What are you going to do about the guy?    Zoloft?

The solution is not obvious; money will not solve this, more hospitals, more doctors, more awareness, etc, do not lessen the burden, they widen the problem.   People are not less depressed than they were 50 years ago, but there are a lot more people who are in treatment for depression.    Figure that out.

Step 1: limit the scope of psychiatry. Limit what we are actually going to call depression, let alone medicate. Limit who we will actually call a patient, and for how long. Not all suffering should be treated.

Step 2: identify why there are increasing numbers of people who are falling through the cracks, despite universal education, social security, and gigantically abundant healthcare. Let alone plenty of jobs and opportunities. The question is not what are we going to do, but how are we defining the problem?   The solution might be the same, but the definition drives the future. Ritalin works, but it matters a lot whether you call it a treatment or an enhancement. Government checks are money but it matters a lot whether you call them "stimulus" or "assistance."

Step 3 is the hardest, most important one: identify why a massive number feel like they are falling through the cracks, even when they are not. What are they being told, being promised, that they do not feel they are getting? What are the expectations, and where did they come from? How are people defining their position in the world?

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===== ====== ===== The Last Psychiatrist: Everyone Goes Crazy In A Different Way, As Long As That Way Is The Same

"yeah, everyone in America is so fake"

The NYT writes The Americanization of Mental Illness:

In some circles, it is easy to make friends with a rousing rant about the McDonald's near Tiananmen Square, the Nike factory in Malaysia or the latest blowback from our political or military interventions abroad. For all our self-recrimination, however, we may have yet to face one of the most remarkable effects of American-led globalization. We have for many years been busily engaged in a grand project of Americanizing the world's understanding of mental health and illness.

The article cites the experiences of a Chinese psychiatrist in the 1990s who tried to explain the culture specific ramifications and meaning of anorexia in Chinese patient: not a fear of being fat, but a vague feeling of GI distress. This was some unconscious manifestation, a somatoform disorder.

Then a woman passed out and died from anorexia on a subway:

In trying to explain what happened to Charlene, local reporters often simply copied out of American diagnostic manuals. The mental-health experts quoted in the Hong Kong papers and magazines confidently reported that anorexia in Hong Kong was the same disorder that appeared in the United States and Europe.

What happened next seemed to surprise the psychiatrist: not only did anorexia rates start to rise, but no longer was it due to the vague GI distress. These new anorexics specifically cited "fat phobia" as the core.

Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they also may have changed the expression of the illness itself.
Dr. Lee surmised that because the language to describe anorexia came from America, then

When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.

There are two points to ponder: first, what are we to do with the genetic basis if the incidence of a disorder jumps so suddenly?

Second, and more importantly: if Chinese people are being nudged into developing western style diseases because they are being bombarded with western psychiatric descriptions, then what do you think happens to western people?

That feeling you have is what Sartre called nausea. Seroquel won't help.

II.

The article, through Dr. Lee, blames the usual suspects:

Mental-health professionals in the West create official categories of mental diseases and promote them in a diagnostic manual that has become the worldwide standard. American researchers and institutions run most of the premier scholarly journals and host top conferences. Western drug companies dole out large sums for research and spend billions marketing medications for mental illnesses... Taken together this is a juggernaut that Lee sees little chance of stopping.

In this case the problem isn't psychiatry, it is the popularization of psychiatry: it is the press, it is the media. She didn't read the DSM, she read the newspaper (and magazines and TV and...) They're not simply popularizing western psychiatry, either-- they're popularizing western culture. It's a safe bet that "local reporters" are going to be more westernized than "locals." But reporters have a forum, so they get to determine the narrative. The "local reporters" in China basically did what the American press does: "here's what we think happened. Hit Print. There, now it's true."

When Google threatens to pull out of China, it isn't because of human rights violations. It's a battle for who will describe the universe. NB: Google will win.

III.

The article describes an experiment that could be called, "You rise to the level of your diminished expectations."

A subject tried to silently train a second person to press some buttons in a specific order. He is told that the second person had a psychiatric disorder either due to "life events" or to a "brain disease." The only feedback they could give was to administer a very mild shock, or a very big shock, when the second person got the pattern wrong.

When the subject was told that the second person had a psychiatric disorder due to life events, they got the mild shock. When it was due to a brain disease, they got the big shocks. If there is already something wrong with their brain, the subject figured he had to make things obvious.

The point of this example was to illustrate that other cultures may end up stigmatizing the mentally ill if they begin to incorporate the Western idea that these are strictly brain diseases. Too late: incorporating the western idea was what gave them the disease in the first place. Seroquel won't help that either.

IV.

"You have a background in genetics. How can you flippantly say that ideas are causing psychopathology?"

The interaction of genes of risk with other genes that we have not yet identified-- say, an insulin receptor or the size of your pancreas or your ability to fight a flu infection-- that we wouldn't even think is relevant, may be quite relevant. Most of our psychiatric genes of risk are risks only in certain environments. That may seem obvious, but consider that a person with schizophrenia, in which the mind has difficulty with reality, may be even more ill when their reality is actually less real: a Chinese teen in China saturated with western images. Perhaps if he never turned on the TV, he never would have developed the symptoms (or they would have been less.)   The Japanese hikikomori phenomenon may be an example.

Go back to the story of the Chinese anorexic woman who died. The article doesn't point put the obvious: she had already been infected by the west. Her name was Charlene.

Certainly I don't hate the west; but when you dip your feet into someone else's culture without the accompanying mental and social infrastructure that goes with it, well, you're going to get anorexia. Or something.

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===== ====== ===== The Last Psychiatrist: Everything's Amazing and Nobody's Happy

worth repeating

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===== ====== ===== The Last Psychiatrist: Experts Weigh In On Bipolar Disorder

And they conclude there's a lot of bad information out there. They try to set the record straight.

Bring a bottle.

From the article:

[The Diagnostic Guidelines Task Force of the International Society for Bipolar Disorder (ISBD)] chairman S. Nassir Ghaemi, MD, MPH ... brought together some of the world's clinical experts on bipolar disorder and key researchers with the goal of having them develop a more systematic and coherent set of diagnostic guidelines.

In other words, what do the best minds in psychiatry have to say about bipolar disorder? What says the latest data?

Also expanded was the definition of bipolar depression, according to Ghaemi. "It is not just depression in someone who happens to have had manic episodes but rather specific kinds of depression with specific features," he said.

...Clinical features include early onset of first depression (before age 25 years), multiple (5 or more) previous episodes of depression, family history of bipolar disorder, atypical depressive symptoms (such as leaden paralysis), psychomotor retardation, psychotic features, and/or pathological guilt.
That's based on the PET scans and the NIMH genetic studies which have so far cost a quadrillion dollars, right? Well, here's a line from the actual Guidelines. It's the kind of line that makes you, well, look upon the works, and despair:

The subgroup describes this as a 'probabilistic' approach to the differentiation of bipolar from unipolar depression, and offers a heuristic of operationalized criteria to be studied empirically. Areas of dissensus persist...

Got that? No? Good, it'll go down easier. So it's soon to be official: Farewell, Depression.

What else does the team think? Oh: schizoaffective disorder doesn't exist.

Most of the evidence, he explained, suggests that schizoaffective disorder does not represent a separate categorical disease entity; rather, it is "a variation on schizophrenia or a variation on mood disorder or co-occurrence of the two." The subgroup recommended dropping the schizoaffective disorder diagnostic category altogether from DSM-V...
The question is, if the evidence has so far been indicating that schizoaffective is not real, why did we have to wait for the DSM to tell us it doesn't exist? Why can't psychiatry simply make it happen?

But the sleight of hand is saying that the schizoaffective is "really" a variation on a mood disorder (read: bipolar.) It is equally plausible that bipolar disorder is a variation of schizoaffective disorder since neither one exist except synthetically. I don't mean the symptomatology doesn't exist, I mean the classification is completely empty. We choose to call this thing schizoaffective, and now we choose not to. We chose to call it depression, now we choose to call it bipolar depression.   It's not like you chose to call it a unicorn but later discover it's actually a rhinoceros. A more accurate analogy is that you chose to call this a unicorn, and now choose to call it a ki-ran. Wait-- what's a ki-ran, you say? Exactly.

Or, you find an elephant's leg, and say, this is an elephant. And next you find a horse's leg, so you say, this has much in common with an "elephant," same joint here, so this is an elephant also. Which would be okay, except then we start making treatment decisions based on that logic: ah ha!   Antifungal cream is the mainstay of treatment for all elephant illnesses! And meanwhile the elephant dies of throat cancer. Does it make any sense that the best of our science suggests that the manipulation of four neurotransmitters is somehow involved in the treatment of every single psychiatric illness known, from anxiety to xenophobia?

What do we say to all of those patients diagnosed with schizoaffective disorder? Oops? Is it any consolation to them, or their families, to hear that it's actually bipolar? How about the criminal cases of schizoaffectives? Should they get new trials? Their new diagnosis of bipolar has more studies to draw from, it has more play in the legal system, and better known to jurors?

As a final question, Ghaemi was asked if he believed bipolar disorder is being overdiagnosed. "While unipolar depression, personality disorders, and schizophrenia have each had periods of overdiagnosis, there has never been an era in which bipolar disorder has been overdiagnosed," he said, "no matter what skeptics claim."
He said that concerns about bipolar overdiagnosis are largely anecdotal, have not been empirically well-established, and ignore solid evidence of continued underdiagnosis.

And there's some more sleight of hand. Empirically? What's the test to see if it is actually bipolar or actually depression? Especially when you have the power to change definitions?

The best is at the end:

The lack of focus on bipolar disorder has led to neglect and controversy, Ghaemi noted. "Our task force," he said, "is a step toward more consensus and less controversy."
Bipolar is the neglected diagnosis? And this will cause less controversy? Are you serious?

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===== ====== ===== The Last Psychiatrist: Family Annihilators Don't Do It Because They Love You

phew?

Newsweek runs a story, Inside the Minds of Family Annihilators. It describes the results of a ten year followup study which found that family murders spike when the economy is down.

The study is not out yet, but the article hits most of the key words:

control
seek to create an idealized version
humiliation
shame
rage

The general thesis is that "when the economy is in decline, jobs are scarce, tensions are high, and the control these men seek becomes harder to maintain."

The article then describes two kinds of family annihilators. One type is:

driven by rage: they are controlling and sometimes abusive figures who derive self-worth from the authority they exert at home. But that behavior typically plunges the marriage into crisis, often prompting the wife and children to try to leave. The resulting lack of control triggers feelings of humiliation, eventually leading the father to reassert his power in a final paroxysm of violence.
Fair enough, easy to spot. But where the article (describing the study) goes wrong is the leeway it offers the other kind: the "altruistic" killer:

The "civil reputable" killer, on the other hand, is motivated by a perverse form of altruism. "His entire identity is in his family"...Murdering his family members, then, becomes a way of rescuing them from the hardship and shame of bankruptcy and suicide.

===== ====== ===== The Last Psychiatrist: Fanapt: Deconstructing A Promotional Slide Deck

Lesson 1: it's pronounced (fa NAPT.) I know, I know.

The intention here isn't to catch Big Pharma in a lie, but to show the data for Fanapt while also showing you the "behind the slides" context. I've done something similar for Geodon and Seroquel (multiple times.)

Some of this material overlaps with the otherst, but I've repeated it here so it could stand alone.

I made these slides mostly from memory or from the PI using MS Paint. They appear different/more professional in the promotional materials, I can assure you.

-------

First, an apocryphal story: Fanapt was named after the Greek word "phaneros" which means to manifest, to make obvious. It was done because the CEO/Founder of Vanda Pharmaceuticals was Greek (Polymeropoulos.)

Slide 1: Pharmacology

Those affinity constants on the right side don't tell you how much of each effect you'll get; they tell the order of binding. It tells you, for example, that the antihistamine effect will occur at a much higher dose than what's needed for the antipsychotic effect.

So what can we expect to happen with these numbers?

At the lower doses, it will act a lot like Risperdal: selective and relatively equal 5HT2a and D2 blockade (Ki between 0.1 and 7nM).
However, it has a1 blockade-- so I expect to see more orthostatic hypotension/sedation than Risperdal, especially as the dose is increased.
Based on the in vitro affinities shown here (which are often poor proxies for in vivo, but I can only work with what I have)-- I'd expect EPS, prolactin, TD, akathisia rates to be superior to Risperdal, comparable to Zyprexa, and worse than Seroquel.

(from Seeman 2004)

On the side it tells you about the 2 active metabolites. The P95 metabolite only shows affinity for serotonin and noradrenergic alpha1 receptors. What does that mean to psychiatry? Nothing: P95 doesn't cross the blood brain barrier. What does it mean to the rest of the body? Orthostatic hypotension.

See that 5HT7 early on in dosing? That receptor is involved in circadian rhythm. I don't know what that means yet, but as far as I know it is unique to this drug.

Slide 2: Pharmacodynamics

This slide is here to tell you that people who are poor metabolizers of CYP2D6 chemicals (e.g. Fanapt) will have higher blood levels. Clinically relevant people are 10% of caucasians and 5% of blacks none of whom you will ever be able to detect. Also relevant are drugs that inhibit 2D6 and 3A4 (Prozac, Paxil).

In drug drug interactions, the order of the drugs is very important. If you are already on Prozac, (hopefully) the doctor will simply observe that you needed less dose for the effect, regardless of whether he was even aware of the reason you needed less (the interaction.) But if you're on Fanapt already, and then get put on Prozac, your Fanapt levels will rise.

Slide 3: QTc

To ===== ====== ===== The Last Psychiatrist: Fanapt Slide Deck

I finished the Fanapt slide deck post, now including weight gain/metabolic data, EPS, prolactin, and an explanation of how to use the affinities.

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===== ====== ===== The Last Psychiatrist: Farewell, Depression

Write this day down: 4/4/07, it is the first day of the new psychiatry. Everything changes, starting today.

Today, in the New England Journal Of Medicine, is an article ostensibly about the lack of additional benefit from adding an antidepressant to a mood stabilizer. This is both surprising and not surprising: surprising, because, well, you'd think two drugs would be better than one. Not surprising because, well, if the first drug worked, why would a second even be necessary? (See #8). And if the first didn't work, how do you know the improvement didn't come entirely from the second drug?

If this is all the article said, it would not be worthy of mention, let alone the herald of a new dynasty.

The study also found that the studied antidepressants did not induce mania. That this should have been prima facie obvious even to a 9 year old without the benefit of eyes (what's an antidepressant? They're not all chemically similar, so why should they all be blamed for the same side effects?) isn't the point here.
The true importance of the study is contained in three statements. If you blinked, you would have missed them.

The first is this:

Mood stabilizers were initially limited to lithium, valproate, the combination of lithium and valproate, or carbamazepine. In 2004, the protocol was amended to define mood stabilizers operationally as any FDA-approved antimanic agent.

The second is this, from the abstract:

Our study was designed to determine whether adjunctive antidepressant therapy reduces symptoms of bipolar depression...

And the third is this:

In summary, for the treatment of bipolar depression, we found that mood-stabilizing monotherapy provides as much benefit as treatment with mood stabilizers combined with a standard antidepressant.

Psychiatry is not about science, it is about language, politics. What's happened here is that "mood stabilizer" now includes atypical antipsychotics; and-- compare what the study was designed to show and what they spun it to show-- we've gone from "polypharmacy is not better" to "monotherapy with mood stabilizers [read: antipsychotics] is just as good as two drugs at once."
There's a subtlety there, and that subtlety is magnificent.
Note the authors: Sachs, Bowden, Calabrese, Thase, etc-- the same people who pushed psychiatry into flowchart polypharmacy; where Depakote was always first line for all phases of bipolar disorder, and any exacerbations that developed were treated with the addition of a second medication.

What the article is saying is that academic psychiatrists are no longer behind antidepressants and antiepileptics. SSRI and SNRI use will decline from here, as will Depakote. They're behind antispychotics. And antipsychotic use is positioned to explode.

It goes without saying: only the antipsychotics are still branded.

But without academics pushing SSRIs, their use will wane--and, importantly, so will their support of the diagnosis "Major Depression." This is going to sound controversial, inane, but it will happen.

Look for upcoming articles finding that "Depression" is overdiagnosed, that it is really just-- life. Look for articles that now find SSRIs aren't that effective after all, that the old "10% better than placebo" is a statistical trick with little clinical utility. That they are way overused in kids.

You might say, wait, isn't the decline of polypharmacy a good thing; that SSRIs are overused in kids; that they aren't that great; and that depression is overdiagnosed? All of this is true, but this isn't psychiatry finally coming to its senses; this is psychiatry entering the manic phase. Sure, it's less SSRIs for kids; but it's more antipsychotics.

Because simultaneously there will be articles pushing the idea that recurrent unipolar depression is really bipolar depression; that there are common genetic or heritability patterns; that the epidemiology and course is similar, etc. The move will be to squeeze out MDD into "life" and bipolar. This done, antipsychotics become first line agents. Oh, and look for antipsychotics to get FDA approvals for kids.

I wish I could make this clearer, but I'm still recovering from my recent bout with death. There's no science here, only a tinkering with language and loyalties, with staggering results. Don't blame Pharma quite yet-- this is a NIMH study.
I am not against antipsychotics, and I have long tried to tell anyone who would listen that the data clearly show they are superior to antiepileptics. But this isn't psychiatry suddenly waking from a coma, aha! it turns out the existing data do show antipsychotics are mood stabilizers!    Instead of using them to replace antiepileptics, they will use them to replace everything: SSRIs, benzos, antiepileptics, stimulants, etc.
And polypharmacy will only be reincarnated-- in the form of multiple simultaneous antipsychotics (Abiliquel, anyone?), with preposterous pharmacologic justifications ("this one acts on serotonin, so it's the antidepressant, and this one on dopamine, so it's the antimanic.")   If anyone says that to you, stab them.
You don't get many changes like this, maybe once every ten years-- the last was the beginning of the Depakote era, and before that was the advent of SSRIs, each with it's own erroneous semantics ("kindling model;" "serotonin model of depression.")
I wish all the patients in the world good luck, you'll need it. Not because of the antipsychotics themselves, which will work or not, oblivious to doctor and diagnosis; but because of the doctors, who take little interest in examining the evidence behind their practice, and even less interest in reevaluating its core principles; and who lack the courage to even treat what they see, instead resorting to artificial, and wrong, paradigms and algorithms. There's not even pseudoscience here. Psychiatry is being lead by the siren call of semiotics, and it is saying, follow me, I am made of words...

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===== ====== ===== The Last Psychiatrist: FDA Discovers That Anticonvulsants Cause Suicide, Too
Or so they find in a preliminary review.

You probably think this is an example of the new FDA, the new anti-Pharma FDA, more attentive to public health, getting their act and their data together for the benefit of Americans.

Ha. Wrong.

I.

The New York Times reports the story, which of course is only half the story.

According to the FDA website, an analysis of almost 200 clinical trials of 11 antiepileptic drugs finds that the suicide rate is almost double that of placebo.

On first glance, this seems like the FDA went to the semiotic school of medicine: "if SSRIs double the rate of suicide, and SSRIs are antidepressants, then antiepileptics, which are also antidepressants, should also double the rate... holy crap, we'd better check."

Popper would be appalled, but psychiatry lives in this world, and so does the FDA. It's insane, but if that's their worldview at least they should be true to it and look for suicide in "logical" places.

Nope. Not even honest in their wrongness. Semiotics isn't what drove the FDA to these conclusions-- it was even more basic than that.

Lawyers.

One lawyer, anyway. Andrew Finkelstein, personal injury lawyer from NY, was handling some Neurontin suicides. How do you make big money? First, you send the FDA all the adverse event reports you can get; then ask them to put a black box warning on it. Black box warning is gold: it means the suicide link exists, it's true-- indisputably so (preposterousness of it aside, of course.) Sprinkle in a dash of off label promotion by Big Pharma and you have yourself a lawsuit masquerading as a self-righteous public service announcement...

It helps to pretend to be for the little guy: "The FDA's complete inaction in protectingthe health and safety of United States' citizens from a known seriousrisk..."

And so, the FDA got cracking...

II.

Let's take a look. The FDA report finds the risk of suicidal thoughts and behaviors is double that of placebo-- just like the doubling of suicide rates for antidepressants.

But not really. The rate increased from 0.22% placebo to 0.43% for anticonvulsants. That's tiny. But it's also not comparable to antidepressants, because the number needed to harm for antidepressants is 50, for anticonvulsants it's 500. In other words, antidepressants are ten times more likely to cause suicide than anticonvulsants.

In the 28,000 people in the seizure drug arms, only 4 committed suicide (none on placebo did.)

I'm not buying the increased suicide risk with SSRIs, but I am sure as hell not buying this nonsense for anticonvulsants.

III.

So, why did it take 4 years to release the data? (Finkelstein has been at them since at least 2004.)

I'm not sure I should even mention this because I do not fully understand it, but I will, if only to give a starting point to others with more time.

Russell Katz, MD is the FDA's chief of neurologic drugs; it is his report on anticonvulsants and suicide that is on the FDA website. He also handled the antidepressant-suicide investigation.

According to an old story (2004) from my San Francisco Chronicle, Dr. Katz may have been involved in suppressing/delaying the release of the antidepressant-suicide data.

Make of that what you will. I'm going to bed.

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===== ====== ===== The Last Psychiatrist: Fearless Kids Go On To Become Criminals

so he was wrong?

In trying to understand, you have to follow that path of the reader, not the writer. Here is what they see.

I.

'Fearless' 3-year olds might be tomorrow's criminals

Children who are fearless at 3 years of age might just be poised for a life of crime. According to a new study, poor fear conditioning at the tender age of 3 can predispose that person to break the law as an adult. Yet other factors, such as education... also play a role, the researchers concluded....

Specifically, what Gao and his associates set out to determine is whether dysfunction of the amygdala, an almond-shaped mass... leads to an inherent intrepidness and disregard for the law.

Every single one of these sentences is a lie.

II.

The study, Association of Poor Fear Conditioning and Adult Crime, is three pages long in which the word "amygdala" appears 17 times. However, the study has nothing at all to do with the amydgala. It measures something that is thought to originate in the amygdala.   To say that "specifically" Gao was studying the amgydgala is like saying that when Fox News reports on Obama, they are "specifically" referring to Hawaii. Nor does the study have much to do with fearlessness as I'll show.

But the news article links permanently three unrelated words: "fearlessness" "crime" and "amygdala."

III.

The study, started in 1970, tested 3 year olds for a "fear response" and then followed these kids over 20 years.

Two decades later Gao and his team tracked down 137 study participants who had committed serious crimes. These individuals had shown an absence of fear during testing at age 3, whereas 274 study participants who had grown to adulthood without a criminal record had displayed typical fear responses.
Create your own narrative: "fearless" babies grow up undisturbed by consequence, punishment, or threats to their own safety, and live a life of immediacy and selfishness.

But "fear" has nothing to do with it. Babies were hooked up to a sweat monitor, and subjected to Pavlovian classical conditioning:   Every time they played a sound (say, "doorbell") they followed it with the sound of a "car crash." So the babies were conditioned to anticipate "car crash" whenever they heard "doorbell"-- and so would sweat more.

Sweating upon hearing the loud noise indicated a sense of fear, while no sweat meant the child lacked fear -- that is, had poor fear conditioning.

Not exactly. Sweating meant they had been conditioned. By example, all babies would exhibit "fear" when they heard only a car crash. What was going on here was that some babies had increased sweat when they heard the doorbell-- i.e. they had been conditioned-- and some didn't.

The false link is to couple "conditioning" with "fear" and then amygdala. But this paradigm isn't really about fear; and while the amygdala is implicated in fear and conditioning of many different kinds that all fall under the umbrella of "fear conditioning" (e.g. taste aversion, etc), the role of the amydgala is drastically altered depending on what conditioning paradigm you use.(1)

Apparently, those that didn't respond to the conditioning went on to be criminals.

IV.

Well, that's not exactly true either.

Results
No main effects of criminal offender group or stimulus type were found. A significant group-by-stimulus inter-action indicated that the criminal offender group failed to show fear conditioning at age 3 (F=4.554, df=1, 409, p=0.033) (see Figure 2). The comparison group (N=274) showed a greater response to the CS+ than to the CS- (t=2.852, df=273, p=0.005; d=0.345), whereas the offender group (N=137) failed to show this effect (t =-0.604, df=136, p=n.s.; d=-0.104).

Those three sentences represent the entire body of information and discussion on the results of the study. The first half of the paper is introduction and methods; the last half is discussion about the amygdala and speculations on the neurobiology of crime that have nothing at all to do with the study they conducted. Go see if I'm lying.

And, you will notice, the study failed on its primary outcome. Here's the context: 1700 kids were studied. 20 years later, only 137 had become criminals. Looking at the original conditioned response data, there was no way to predict which 137 were going to become criminals. Starting with the criminals and working backwards, they were only slightly less responsive to the conditioning than a selection of controls.

V.

So what do the results mean for individuals with fear conditioning deficits and their loved ones, and for society at large? It's a wake-up call about potential problems, said Gao and other experts in the field. To enhance the proper working of the amygdala, which is believed to reduce criminal behavior in later life, enrichment programs are essential.

I'll admit, having lived through 20 years of the "decade of the brain" I didn't fully appreciate the shift in direction modern psychiatry was taking. They have moved from a "fixed trait," "everything is genetic" bias, to a "neurodevelopmental dysfunction" bias.

The importance of this bias is entirely social, not scientific, as the science itself is the same, only the interpretation differs. This new interpretation allows early intervention programs to target the biological aspects, and not the social aspects. It justifies psychiatry to use its techniques for social change, which it had previously been doing without official sanction.

You say: "Are you insane? We couldn't do anything about criminality before; now maybe we can. Why is that so bad?" Because you can't do anything about it at all. Because you can't do anything about it at all. You had these same medications and techniques before but they didn't work and you didn't really expect that they'd work. Believing that they will work now won't change anything.

This is the reclassification of social ills as "neurodevelopmental disorders;" the offloading sociology to psychiatry.

Addressing parental concerns, Benedek added: "Don't be discouraged if your child has early brain dysfunction. It doesn't mean that he or she is going to grow up and be a criminal. The brain can change and grow."

My God, my God.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Federal Judges Order California To Release 50,000 Inmates
Oh, look, expediency masquerading as a constitutional issue.

The story is

SAN FRANCISCO (Reuters) - Federal judges on Monday tentatively ordered California to release tens of thousands of inmates, up to a third of all prisoners, in the next three years to stop dangerous overcrowding.
California currently incarcerates 160k people at 188% capacity, and the ruling would cut it to 120% capacity.

The obvious: the nonprofit Prison Law Office-- "protecting the constitutional rights of California prisoners"-- says the prisons are overcrowded, facilitating the spread of disease, there is inadequate medical facilities, it is a dangerous environment, etc.

"There is no relief other than a prisoner release order that can remedy the constitutionally inadequate medical and mental health care," the panel led by Court of Appeals Judge Stephen Reinhardt, wrote.

No relief? If this was simply about the safety and dignity of the inmates, you'd ask the Obamyth for some TARP to "create jobs through public works projects" and build, I don't know, 100 more prisons.

If it was about a broken criminal justice system, you wouldn't incarcerate people for, say, marijuana possession, no matter how many times they "offend." If the sociobiologists think it really needs to be criminalized, then make the punishment be a fine, or community service.

If it was about a broken criminal justice system, you wouldn't jail people pre-trial for six months and reschedule the court date over and over because it's busy-- with marijuana trials, I guess.

That's not what it's about.

It's all about "mental health care." Psychiatry is the new parole. What, you think they're just going to release 50,000 people with no job, prospects, or particular motivation into the wilds of California? They'll get sent to psychiatry: some will go to outpatient; some will go to state hospitals; many of them will go on disability.

Which is fine for some, maybe they need it. And sure, it's better than prison, drinking lava is better than prison. But let's not pretend this is about overcrowding.

This is simply a re-characterization of a social problem as psychiatric. Society is faced with two choices: either there are a lot of bad people in the world, or there are a lot of sick people in the world. Society doesn't really know how to solve either problem, but at least the latter is neither its fault, nor its problem.

Reclassifying a criminal problem as psychiatric lets you do three things: lower your expectations that criminals will change ("biological diathesis, we still don't have great treatments"); enjoy civilized society without having to wonder why it might be generating more bad guys, not less; not worry about all that tiresome speedy trial/ court appointed lawyer/ due process nonsense, because in psychiatry, there is no due process, just utilization review.

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===== ====== ===== The Last Psychiatrist: Fifty Percent of Foster Kids Are On Psychiatric Medications

That's right. The single most best predictor of mental illness-- better than family history, better than genetics, better than symptomatology-- is being a foster child.

Texas data: 2004, 40% of the 32,000 foster kids were on psychotropics. 2005 it was, by age:

0-5: 12.4%
6-12: 55%
13-17: 66.5%
Do you understand the significance of this? If you tell me every single person in your family, including your identical twin, has schizophrenia, I will not be able to tell you if you have it-- but if you tell me simply that you are a foster child...

I'm sure someone has an explanation that deals with 5HT-2a receptors, or the amygdala, or genes on chromosome 12, but:

"When two-thirds of foster care adolescents receive treatment for emotional and behavioral problems, far in excess of the proportion in the non- foster care population, we should have assurances that the youth are benefiting from such treatment," said Dr. Zito.
Damn right. But as I said in my Esmin Green article that failed to convince anyone, this will never really be explored because society doesn't have any other options.    If you don't call 16,000 Texas kids "early onset bipolar," does the system have a Plan B? Jail, I guess.

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===== ====== ===== The Last Psychiatrist: Finding Existential Solace In A Pink Tied Psycho

unamerican

Forbes: "Stock Traders Are Psychopaths"--

... a University of St. Gallen study that shows stock market traders display similarities to certified psychopaths. The study... compares decisions made by 27 equity, derivative and forex traders in a computer simulation against an existing study of 24 psychopaths in high-security hospitals in Germany. Not only do the traders match their counterparts, but, as Der Speigel [sic] succinctly puts it, the "stockbrokers' behavior is more reckless and manipulative than that of psychopaths."
Der Spiegel:

Using a metaphor to describe the behavior, Noll said the stockbrokers behaved as though their neighbor had the same car, "and they took after it with a baseball bat so they could look better themselves."

The researchers were unable to explain this penchant for destruction, they said.

Hold on. The study compared institutionalized psychopaths to a group of German traders and found the traders are worse psychopaths, with a "penchant for destruction." Umm, how about the more obvious explanation" they're German. What? Too soon? Hello? Is this thing on?

The preposterousness of my comment is only slightly less than the overall idiocy of this study and the reporting around it. Following a rigorous objective analysis, the fact that the traders were German is a more plausible explanation for their baseball bat smashing behavior than their employment as traders. I realize the institutionalized psychopaths were also German, but the presence of mental illness is itself a greater confounding factor, i.e. in a study of psychopathy, the general order of important factors can be approximated:

mental illness > species of pet > race > employment > favorite movie > phone number

in other words: this study is stupid, which is also a rigorous objective analysis.

But the existence of confounding factors did not stop nearly everyone from turning up the volume of their own cognitive noise:

NYMag:

With rogue traders all the rage, a Swiss university study found that brokers "behaved more egotistically..." The study's co-author Thomas Noll said, "Naturally one can't characterize the traders as deranged..." Particularly shocking for Noll was the fact that the bankers... Noll said it was as if the stockbrokers realize...

Of course I can't find the study anywhere, which is suspicious, but not ===== ====== ===== The Last Psychiatrist: First Anniversary Of The Death Of Antidepressants
Belated, anyway.

A year ago-- 4/4/07-- the NEJM published a study that said\ antidepressants did not provide additional benefit to mood stabilizers. But my tin foil hat allowed me to see that the authors were abandoning antiepileptics and antidepressants; the future was in bipolar, and in antipsychotics.    We are now for monotherapy, and it is branded.

I wrote about it then, received slightly more than the usual hate mail ("are you a psychiatrist or a scientologist?") had a drink and went to bed. What else am I going to do?

Time passed. Seroquel got an indication for bipolar depression; Abilify for adjunctive use in depression. SSRIs are history, Cymbalta a last holdout due to an extra indication. And I haven't seen a Depakote rep since, well, since a year ago.

If you're new to the game, it will be hard for you to believe that in 2001 Depakote was everywhere. If you dared to start a "bipolar" on anything other than an antiepileptic, you were actually reprimanded by other doctors. "What the hell is this nut doing over there?"    Back then if you said you were going to use Seroquel for... anything, they caned you.

Now it's the top selling psych drug.

I briefly toyed with asking Calabrese, Bowden, Sachs, et al-- the Mafia of Psychopharm-- for a formal apology; or at least an admission that they were wrong, but now I see that that's impossible: not because they are hiding it, but because they actually believe they never said it. They think they were always pro-antipsychotic monotherapy; that they never intended Depakote to be first line; that they never implied there was considerable evidence that Depakote should be a maintenance agent, when in fact there was none. They don't realize how much a pawn in the academic-Pharma game they are.

I fought a solitary battle against this thinking back then, and I'll say it was with some not inconsequential professional repercussions.

Whatever; my point isn't to say I was right, but to show that they were wrong--and now pretend they never said it. So that the next thing they say can be met with at least a little skepticism.

It's like Iraq-- first it was WMD, everywhere, all the time; now they don't talk about WMD, but worse, they pretend that they never really meant WMD.

Difference is no one trusts Cheney anymore; but somehow, we still ask the Mafia of Psychopharm to lead us.

I'd trust Cheney over any of them, any day.

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===== ====== ===== The Last Psychiatrist: First Person Account Of The Milgram Experiment

An article written by one of the test subjects in the Milgram experiments, and his explanation for why it happened the way it did.

He's wrong.

First, if you do not know the experiment (video): a "learner" would be strapped to a chair in the next room-- so they could be heard, but not seen-- and would be asked to remember words from a pair. If he got it wrong, the professor would tell the tester to operate a machine that would remotely administer electric shocks.

In reality, the thing was staged; it was really an experiment to see if the tester would submit to authority: "please continue administering the shocks."

Most "testers" continued to shock as long as the professor told them to, even though they could hear the learner howling in horrible pain. Perhaps they thought the scientist had some safeguards from actual death, who knows. But the results show that people are sheep given the right power structure.

This article is by one who refused to continue giving shocks. His reasons for stopping are interesting:

In retrospect, I believe that my upbringing in a socialist-oriented family steeped in a class struggle view of society taught me that authorities would often have a different view of right and wrong than mine.
He goes on to detail the origins of a default suspiciousness of authority:

Like all soldiers [in WWII], I was taught to obey orders, but whenever we heard lectures on army regulations, what stayed with me was that we were also told that soldiers had a right to refuse illegal orders (though what constituted illegal was left vague).
and his battles with the government:

In the early 1950s, I [the Chairman of the New Haven Communist Party] was harassed and tailed by the FBI, and in 1954, along with other leaders of the Communist Party in Connecticut, I was arrested and tried under the Smith Act on charges of "conspiracy to teach and advocate the overthrow of the government by force and violence." ... I believe these experiences also enabled me to stand up to an authoritative "professor."

I have a personal bias against communism, so I'm skeptical of this answer. By invoking communism/socialism, he is implying that he has a higher sense of rightness than others might, and some attachment to the common man that made him not want to proceed with hurting the guy on the other end of the shocks. Before you read further, read his quotes again and see if you agree with my assessment.

But here's why he refused:

...[the professor] insisted that I continue [giving shocks.] I refused, offered to give him back the five dollars, and told him that I believed the experiment to be really about how far I would go, that the learner was an accomplice, and that I was determined not to continue.

He didn't stop because of moral courage; he stopped because he thought he was being played.

The distinction is extremely important. His life experiences didn't make him strong against against authority, but to be suspicious that authority is an authority.   He stopped not because the other person was being shocked-- what he cared about was being manipulated.

And so again, narcissism, though in this case resulting in a "healthy" outcome because it heightened his perception of games and manipulation.

I'm not criticizing this man-- what he did in this experiment isn't generalizable to other circumstances precisely because he thought it wasn't real.

A more interesting question would be how much further he would have gone if he didn't think it was a trick; when would moral courage as opposed to indignation have taken over?

Let's be clear that there is a difference between not playing because you think it's rigged, and playing despite it being rigged, doing the best you can anyway, because that is what life is...

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===== ====== ===== The Last Psychiatrist: Forget Paypal- This Is What Blogging Is All About

The best endorsement I've ever received. Take that, Malcolm Gladwell.

Wow. I'm going to need a minute to collect myself.

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===== ====== ===== The Last Psychiatrist: Four Things Not To Do To Your Kids
Apart from letting them watch Japanese horror movies.

John Gottman, from the University of Washington, has a "marriage lab" in which he videotaped/s married couples disagreeing about something minor, in order to study predictors of divorce. He came up with four.

You might think they're obvious, but if you actually try to avoid them during an argument, it's harder than you think. Try it.

It then occurred to me that these often some of the same reasons why some kids "hate" their parents. Again, you'll think it's obvious; but again, try to avoid it when talking to your kids.

Disclaimer for the sensitive: the below are inflated examples; these are done to varying degrees, of course, sometimes it's unavoidable, etc, etc.

Criticism:

The most difficult to avoid. Parents may not realize how a majority of their interactions with their kids are comprised entirely of criticisms.

"Did you put away your backpack?" means "I know you didn't put away the backpack." It's worse when mom doesn't even bother to check, she just knows it. That drives kids bananas. "What is it about me that you just assume I don't do anything right?" What it is, of course, is history-- he hasn't done it the past 20 times. Kids are empiricists though not statisticians. Past doesn't count: if you don't check now, then you can't know now.

The kid thinks, mom just assumes I do things wrong. Ultimately, this means he stops trying.

It teaches one other awesome message: it doesn't actually matter what I do, only what people think of me.

Stonewalling:

Stonewalling means: "I am not going to discuss this with you." It means the kid has no say, no voice, there's no one to appeal to, even logic. When a kid doesn't feel people will seriously consider their position, they'll go find someone else who will. That person will have weed.

Stonewalling teaches kids that those who have more power simply don't care to hear you. So they avoid the attempts at dialogue and try... alternative means of communication, e.g. not through words, but actions or the creation of emotions. And weed.

Defensiveness:

NB: this is done by the parent.

In a marriage, defensiveness takes the form, "hey, don't blame me, you're the one who told me to do this." But you can't look at that defense and deduce who is actually at fault.

But when a parent does it to a kid:

1. the kid is criticizing the parent.
2..the parent is actually in the wrong, caught by the kid;
3. the kid has latched on to this single instance of parental wrongdoing to unload all of their pent up hostility, in the form of criticism about this single issue.

And so, the parent, defensively, tries to flip it: "the only reason I did that is because you...." That's disaster.

Kid: you always break your promises!
Parent: no I don't, but if you would just give me a moment to myself, I would have been able to...

Kid: you lied to me!
Parent: I didn't lie, but you were going to X, so I had to Y-- if you hadn't done X, I wouldn't have had to Y.

The kid understands that even when he is right, no one will care. He realizes he'll be used as a scapegoat, forever, by those more powerful than he. Now where's that weed?

Contempt:

It is said (by me) that rolling the eyes is a more reliable way to divorce than recording yourself cheating and then asking your wife to pull some highlights clips. Seriously, this is true. Anyone want to fund a clinical trial?

Why is the toy store a reliable place to hear a parent screaming at a kid? It's a toy store, what did you expect he'd want to do there?

I sense your frustration. It's the same frustration you have with the toll booth operator who can't count the money correctly, you think, "what an idiot!" but you don't think it through: you expect the toll booth guy to function at the same intellectual level as an engineer. Is that reasonable? If he was smarter, he wouldn't be working in a toll booth.

Yet frustration is released on the kid as contempt: the speaking with disgust, the sneering.    "Jesus Christ, what is the matter with you? Are you retarded? Is this what you do in school, too? No wonder you can't read." You don't see you do it, because you think it's a brief interaction out of your day. But the kid feels the full force of it, and it represents a significant minority of the interactions he has with you. "I'm going to beat the crap out of you!" even though you've never actually done it. The kid knows you're not actually going to hit him, so he figures, "this nut hates me."

If you roll your lips inwards while you yell at your kid, you're pissed at him. If you find yourself jutting out your bottom jaw, you hate him.

I know, I'm sure you don't hate your kid, but like I've said a thousand times, you don't get to decide who you are, your actions decide. If the kid, most of the time, hears contempt, then you hate your kid.

Go ahead. Write on a piece of paper the tone of every interaction you have with your kid for one day, and tally it up at the end of the day.

Have a good night. Sweet dreams.

I'm going to add one more of my own:

Ultimatum/Consequences:

You can't say to a four year old, "if you don't put that down, you're not going to watch TV later tonight." That cannot possibly work, ever-- do you really think the kid can process this consideration of the future, especially since you're not really rigorous about applying it after all?

In truth, you want them to do something only because you want them to-- which is fine. So say it that way: "Put that down." That's it. Teach them they have to do what you say because you said it, period. Don't subsume your authority to some other power in a reflexive attempt to make things happen: "If you do that again, you're going to your room!" Now the room has more authority than you do. And it gives him the opportunity to test: "I'm not afraid of my room."

Instead, say only: "Don't do that again." And if he does, then send him to his room.

Some things are wrong, regardless of consequences. The sooner a kid learns he has to behave certain ways not because of anything, but just because, the sooner he'll be able to develop his own superego strength.

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===== ====== ===== The Last Psychiatrist: Fox & Friends punked by Obama supporter

definitely going to vote for Obama

Oh, look:

===== ====== ===== The Last Psychiatrist: Friday Diversion: Jonathan Coulton

Not his best song (that'd be The Future Soon or maybe Code Monkey) but reminds me of psychiatry. The other songs are so-- accurate. If you don't get them, then you weren't there.

The guy is a awesome. I am so learning the guitar.

For those who don't know, he's a former programmer (in VB, no less-- before .net) who had always had the lingering (nerd?) dream to become a musician. So he quit. Two extra points: he was already married with a baby, and as far as I know he didn't live on top of a uranium mine; it was recommended to him to try and write a song a week for a year-- and he did.

It's a stunning thought, to the point of vertigo, how much time and energy and sweat and blood we invest in a life we don't actually want. On your knees every night, praying to make it-- into college, into law school, into the sales job, into the management slot, into, into, into... only to be in the second week and think, wait a second, I think I've made a very serious mistake. I'm guessing anyone married before 2001 has had the same thought about their marriage.

The problem is the upbringing. Don't laugh. Parents like to think that there are multiple paths to success and happiness, but somehow they all involve good grades, college, a job, a tie. The saddest part is that the parents should know better: do you want your life for your kids? Do you look at your 2 year old daughter and think, I can't wait to break her spirit and her faith in humanity?

It is no surprise that the people we admire took alternate paths.

And no, it's no surprise psychiatry is a massively growing industry. I'll wager: never has there been a greater disconnect between id and ego in the near total absence of superego. That's right. Look it up.

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===== ====== ===== The Last Psychiatrist: Frosty The Snowman

there are worse things than being alone but it often takes decades...

It was 1979 and the boy was 7 and playing a Mattel electronic soccer, and Karen was 3 and resting her head on her mother's thigh, but the other part of it was that they were in the hospital and her mother was dying.

The accident put the mother into a coma immediately, but left her that way for another ten hours, nine of which were dreadful waiting. Waiting for something to happen, waiting for it to be too late to stay any longer, waiting for a doctor to come and tell them what the test that they had waited for was going to show.

The father was there, just coming up to sober. He had given the kids the soccer game to distract them so he could process his grief.

There was a nurse there as well, she tried to offer the girls some juice, but Karen didn't want any juice.   The boy scored a goal so no one offered him anything.

The mother let out a gasp, then there was some sort of rushing and organized chaos as the medical staff moved parts of her body around and family asked frenzied questions, within a few seconds more doctors were there, more nurses, and both kids were pushed to a corner where they both stared at futility.

Eventually it was over. It had actually been over well before that. But.

There is a moment, it comes immediately after the doctors stop working and immediately before you understand that the person is forever dead, where time pauses. Everything stops. That stillness is inviolable, it is at that moment when you witness quantum physics choosing between potentialities, you are watching it decide that this not that will be, this is what will be what has happened.

It was in that sacred moment that Karen chose to sing.   "Frost-y the snowman! Was a very happy soul--"

She never actually got to "soul," because by "Frost-" the back of her father's hand slapped her in the face with such impulse that she fell over.

It was a reflexive slap, the song was such an affront to the family and to quantum mechanics that his hand got to her face even before his eyes did. Everyone winced. No one said anything. The staff looked away, down, up, at machines and papers. The original nurse put a smile on and lead the kids by the hand outside. Maybe there was some ice cream there, let's leave the grown ups to talk.

"But I want to sing Frosty!" said Karen. " Just one time?!"

II.

The problem with guilt, unlike shame, is that it is with you even when you are Alone.

Karen grew up and carried the guilt of that accident with her, the guilt of that single instant: she had distracted her father in the car. Too loud. Dropped the Oreos.   The father had turned to look at her, yell at her. The only part that wasn't really her fault was that no one wore seat belts in 1979.

Thirty years later she didn't even have solid memory of her mother, but the accident and the hospital were in hi def. Her brother's descent into drugs, her father's decline into nothing, all had happened because she hadn't been able to save her mother. Not directly, but inevitably. No matter how you worked backwards from the splitting of 30 years of potentialities, they all started with the dropping of the Oreos.

And she had run through in her mind, in those 30 years, every other alternative potentiality: if she had simply sat quietly; listened to her father; died in a fire; died in utero... so many other possibilities and if any of them, therefore her mother would still be alive.

But those were unsatisfying fantasies, because they didn't change the source of her guilt which was, she knew, the dropping of the Oreos.    That's what had to change, the opportunity missed.   Then her mother would be alive, then she would have succeeded, then the guilt would be gone.

She parented differently now that she had a 3 year old daughter of her own, it was all four point harnesses and Chevy Suburbans and no snacks in the car.

But you can protect your kids from the world, you can't protect them from you.

When the family goldfish died Karen decided to use it as a teaching experience for her young daughter. They'd take the fish outside and bury it, and say a prayer, and in this way would learn about death and God and about the enormity and ceaselessness of the universe, that life is finite though memories are not.

But what do we know about the universe that we think we can teach? We humans fret about personality and behavior and the relative contributions of nature vs. nurture, but if someone asked God if they should study Francis Crick or Carl Jung, He would spit in their food. Get thee behind me, Satan.

When Karen sat Catherine in front of the bowl, in that instant of silence when Catherine should have been watching quantum decoherence, she instead did this:

"Frost-y the Snowman! Was a jolly happy soul! With a corn cob pipe--"

And the mother snapped. "CATHERINE!"

Catherine's head jerked back. Her eyes darted to the dead fish.

"Why are you singing THAT?!"

Eyes darted back to the mom, back to the fish, back to the mom. "--and a button nose--"

"Stop! Why are you singing that?!"

A sob came up first, back and forth went the eyes. "...I have to."

"Why?!"

"So he'll wake up..."

Nothing in that room moved, except a flow of tears and Catherine's eyes, watching quantum mechanics take away her beautiful fish.

"... but now it's too late..."

-----

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: FTAC: Forensics Gone Awry, And I told You So

Following from my premise that the erosion of civil liberties and descent into fedualism necessarily coincides with the rise of psychiatry, I found a short article in the Economist, the magazine of record of the Whig Party, which explains that British Government runs a "Fixated Threat Assessment Centre," i.e. capturing stalkers. It has 4 cops, and a forensic psychiatrist and psychologist.
You probably think that the shrinks are "profilers." Maybe they are. But their real value is in their power to do what cops can't: involuntarily commit people who they feel are dangerous.    Quoting the Economist:
The Met [cops] defines its [suspects] as those who are "abnormally preoccupied with certain ideas or people." The inclusion of "ideas" gives it wide remit. Could those abnormally pre-occupied with the idea of jihad-- or, indeed, human rights-- be considered fixated individuals?
Disclosure: I actually think this is clever-- why not tap the legal resources of psychiatrists to help catch bad guys? But that's exactly the point: no one should have the ability to use that power extra-psychiatrically. It's seductive and it has no recourse for appeal, no controls.
The article goes on to state the FTAC has been operating for 8 months with no official announcement; it won't say how many people it has caught or tried; and, of course, it can't, because of confidentiality of the "patients."
Good luck, everybody.

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===== ====== ===== The Last Psychiatrist: Funeral

do you have a better system?

The funeral is attended by 30 people. It's a military funeral because he was in Korea, and in the front chairs are his wife and two grown children, and they are quietly crying.

When it ends, people disperse hesitatingly, after all, they themselves aren't sad, they didn't know him, they knew his kids. So they are unsure of what they're supposed to do next, but the answer is you keep going, there's nothing else to do but that. That's the point of a funeral.

The deceased's wife has mourned her part, for now, and accompanied by her adult son walks away. The adult daughter approaches the coffin, sobbing. She is pretty, which unfortunately is relevant. Her husband hugs her, and then takes their two little girls away from her, down towards the road, giving the woman the required freedom to be someone's daughter one last time.

She kneels at the coffin. She cries. Everyone can hear it. It is sad.

II.

But some people are unsatisfied with a system that's been in place for more millennia than years they've been alive. They don't trust that it's effective because when the funeral is over people are still sad.   What kind of stupid ritual is that? These people want to change the system, they believe they know a better way.

Most people instinctively turn away and give her some kind of privacy, but about ten of them move forward to surround her: what's this? A woman crying? At a funeral?? They huddle around her in a semi-circle, hyenas waiting for a signal. One hyena steps forward, tries to hug her from behind; and you can see the surprise in that dummy's face when he doesn't get the expected hug back, when it doesn't seem to help, the grieving daughter doesn't stop crying, she doesn't even get up. The hyena is caught awkwardly, so he rests his paws on the woman's shoulders, and now the sobbing woman must associate her last chance to be with what is left of her father with the stale breath of a sycophant waiting for his moment to be relevant.

And while that's going on others are whispering to the quivering back of her coat, "oh, I'm so sorry", "I'm sure he really loved you", "are you ok?"

Why did any one of them think they had the power, the right, to interfere with another person's mourning? This was between her and her father and God and no one else. Did no one notice that even the husband had given her space? Did they just think he was being a jerk? "I just wanted to comfort her." No, you didn't know what else to do, so you did that. "I didn't want her to be alone."   That's because you are a terrible person.

They do not know how to stand in the presence of grief because they can't help but make it immediately a judgment of themselves-- how can you see a woman crying and not do anything?    Purposeless hyperactivity to cover up one's impotence and lack of empathy. "But I'm not the one grieving, I can't fake being sad." Don't fake it, just be silently and unobtrusively available. I know you don't think you're the most important person there, but you are also not the second most important. Or the third or tenth. Get out of the way.

But they can't, they think it has suddenly become their responsibility to save you. Look around, all those other people-- yours? Do you think you can? Do you think that anything you say is going to bring the dead back? Ease her suffering?

She's supposed to be sad, she needs to be sad, if she wasn't crying enough I'd kick her in the shins to make her, otherwise she will hold all of that emotion and let it out piecemeal over three decades and she will be lost.

These animals suffer from a deep existential pathology for which there is no cure, in ordinary times they will be the most ordinary people but when the ship goes down they will kill each other to make sure they get a lifeboat all for themselves. Medicine won't help this, religion won't help this. On the one hand they don't know how to be real, on the other hand they they think protocol and formality is dishonest and insensitive. They can't say, "my condolences" because it sounds fake. So they improvise, catastrophically.

We should all be so lucky that as adults we get to attend our father's funeral, doesn't make it easier but that's a fact, because the alternative is that it happens the other way around, and I can think of nothing worse than the other way around. But even then the system is in place, if you blindly follow the steps-- if people let you blindly follow the steps-- then when you are finished you can begin to go back to your life. Death creates a hole in your heart that is unfillable, but if you follow the steps you can at least fence it off so you don't keep falling in.

There is no shortcut to mourning, the shortcut leads to madness. When you subvert the system and offer a mourner a shortcut, you are leading them to madness.

But how can she let go, how can she do what needs to be done, under the oppressive gaze of self-conscious people who need her to know they came? "I just want to support her!" Then you'd go back to your car, connect a hose from the exhaust pipe to a slightly opened window, and wait it out.

When she first told people about her father's death it came with a gift to others, a qualifier: "I won't be there on Wednesday, my father passed away and I'll be at the funeral-- it's ok, I'm fine" but nevertheless grown neophytes went to Defcon 5. This is one such text message: "OH MY GOD, ARE YOU SERIOUS! OH MY GOD, I AM SO SORRY, WHAT HAPPENED?? PLEASE CALL ME IMMEDIATELY!!" The text message ends there because I smashed it.

One man, either a friend or a blastoma, came to the funeral luncheon mostly to ask the daughter what was up with her girlfriend he was trying to date. He's 50. I know he didn't think he was being selfish or insensitive, he truly believed she'd welcome the chance to talk about his relationship, she'd want him to be happy, she'd use this sad day to tell him how love was the most important thing in the world and he should seize it because life is so short. That's how it happened in Four Weddings And A Funeral, anyway. I will bet you all of your money that as he got dressed in his black suit and lavender shirt, inside his head was playing, "going to the chapel and we're....." Did he come to support her? No, he came to destroy the world.

Six different psychopaths called her to demand they come to the the funeral to "show their support." Who do you think you are fooling? Each of them wanted to be the best friend that would accompany her through the terrible day. Each of them believed that they were the best friend that would do this. But just because she's on the phone with you all the time solving your crises, it doesn't make you a best friend, it makes you a patient. A real best friend wouldn't use a funeral as a way of solidify their own place as "best friend." A real best friend wouldn't feel jealous that some other friend got to sit closer, got more attention.

One psychophant who came to the luncheon to "show support" didn't get the extra acknowledgement she expected, so she decided instead to perform unsolicited grief therapy on the woman's five year old daughter. "Since we didn't get a chance to connect at the funeral," she said later, "[your daughter] and I had a good talk about what happens when you die." If I had seen this happen I'd be in prison now. The only thing this woman can connect with is a phone charger, the battery is always dying.   "Hi, I just texted you, I wanted to see if you were free to talk about me, but I only have two hours."

It's not your day, your method sadness is irrelevant, your pseudo-concern transparent and you are forcing mourners to divert their attention to you. "I had Christ in my mouth for over an hour!" was a post funeral text from a woman who... what? I'm not a Catholic so it took me a few minutes to piece together that this lunatic meant she had kept the Eucharist from the funeral mass in her mouth without swallowing it for an hour-- as if that meant something. Woman, you are insane, your personal relationship with Jesus is pathological, I'll guess you voted for Romney but you are the reason Obama won.   It's bad enough you think your God wants you to be an hysterical neurotic, but why would you then tell this to a woman mourning her father? Why would you think she'd derive comfort from what you did?

It's no surprise that the new DSM removes the bereavement exception from the diagnosis of depression-- no one allows normal bereavement to occur. How can ordinary bereavement ever occur when it is subverted, worsened, at every turn by people who were never taught how to act around other people, who just don't know? "I just want to help." You are destroying the world.

I understand funerals can be awkward for those not directly grieving, but over-exaggerating your pretend sadness is of no benefit to anyone, it merely obligates the survivors to manage your fake concern. If you feel compelled to speak in all caps or explain how terrible this all is to a person who knows first hand and way better than you how terrible it all is, don't. Stay home. When you find yourself in the presence of mourning, simply say, "I'm sorry for your loss. If there's anything I can do for you, please let me know," and if he happened also to have been a great man you can add, "he was a great man," then bow your head and fade to back.   That's all that's necessary. The system will take care of the rest.

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===== ====== ===== The Last Psychiatrist: Further Thoughts on Competency To Be Executed

I took the data in the paper "Killing the Willing: "Volunteers," Suicide and Competency" and drew this chart.

The paper is fascinating. It observes that although blacks are disproportionately represented in executions versus the general population, volunteers to be execute-- i.e. people who waived their appeals-- are overwhelmingly white, male, and have psychiatric illnesses, especially borderline, depression, and psychoses (and an additional 10% have substance abuse)-- which is basically your demographic for suicide attempts. 30% also had prior suicide attempts.

So the author asks: if there is no such right to assisted suicide (indeed, any suicide at all), can there ever be a waiver of the appeal in capital cases? Even if the defendant is competent, if suicide is a motivation, the author writes, "their decisions should not, indeed must not, be honored, at least so long
assisted suicide is not available to other persons in the jurisdiction."

The counter argument, of course, is that competency is a legal matter, and the person's motivations beyond that are irrelevant. For example, if a guy is sentenced to prison and wants to go, he still goes.

McClesky v. Kemp (1987) attempted to abolish the death penalty under the argument that executions were influenced by racial discrimination. This was rejected. But Atkins v. Virginia (2002) did abolish the executions of the mentally retarded. Consequently, abolition of the death penalty, or at least a drastic curtailing of it, is more likely to occur along lines of competency and mental state, rather than any appeal to morality, race, or class.

I thought I knew how I felt about this issue, and now I am not so sure. But before anyone forms their opinion, I would strongly urge everyone to read the dissent by Scalia in the Atkins case. It should be required reading for every psychiatrist, whether you agree with him or not.

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===== ====== ===== The Last Psychiatrist: Geodon Is Not BID

If one more person tells me Geodon "doesn't do anything," I'm going to choke them with the capsules. If it's never worked in your practice, how do you explain the numerous efficacy studies? All flukes? All of them? It couldn't be you?
Probably everyone has heard Geodon must be taken with food. But that's not to prevent nausea or protect the stomach lining, it's to get the drug to be absorbed.
You'll have to take my word for it right now that 120mg is the a base dose. (120mg Geodon=10mg Zyprexa=3mg Risperdal.) This is amazingly hard for psychiatrists to appreciate ("there are equivalences? And those are the doses??") But it's even harder to get them to understand the relationship to food: Geodon needs fat to be absorbed.

80mg on an empty stomach (blue line) gets you the equivalent of 40mg if taken with food. That's half the dose. In other words, if you dose your Geodon "all at night" (no food) then you're getting about half of what you thought you were. (In chronic dosing this will be less of a problem, but 30-50% increased absorption with food is a good guideline.)
Hospitals: they dose BID, which means morning and night, which means no food either time. Guess what happens (or doesn't).
BTW, crackers won't do it. The graph above is with 800 calories, 400 calories of fat. That's a meal, not juice.
If your doctor gives you less than 120mg and then gives up, he doesn't understand the proper dosing of Geodon. If he doesn't know about the importance of food, then you're in big trouble. Forget about reading journals, he's not even listening to the reps. (I know: because they're biased.)
I bring this up partly as a public service message, but also to explore the curious observation that even though many doctors know this already, they still don't dose with food. I can't imagine laziness is the answer. There is some weird thinking that this isn't relevant in the "real world" because food is weaker than medication. Drug-drug interactions matter; drug-food couldn't be important.    And if it was really important, someone e would have mentioned it.

Everyone complains about diabetes and weight gain; here's a drug that likely doesn't have these problems. But because it doesn't have those toxicities, it therefore can't be "strong," or effective.
I'm not trying to advocate for Geodon. I'm pointing out that much of our perception of a treatment's efficacy can come simply from our mishandling of it; and to alert humanity to the inherent bias in ourselves. If we've never gotten Geodon to work, then not only do we think it doesn't work, but we think everyone who says it does work is a Pfizer schill.
Seroquel had this problem, too. Six years ago, no one used Seroquel. Now everyone uses it. Did they improve it? No. It's marketing, but in reverse: Astra Zeneca didn't delude everyone into thinking it works when it doesn't; we deluded ourselves into thinking it didn't, when it did. So whose fault is that? Depakote: six years ago Depakote was untouchable, it was the king of bipolar treatment. Now? Did we get new data saying don't bother? Did they make the drug weaker?   This is the key: the data that brings us today's conclusions is the exact same data that gave us the past's, opposite, conclusions. In other words, no one actually read the data; they based their conclusions on something else. Clinical experience? No.
The bias goes well beyond "Pfizer paid that doctor off"-- it comes from a belief system ("meds are life savers" vs. "meds are band-aids"; nature vs. nurture; your own race/gender; your family history of mental illness/drug abuse (or lack of it); your desire to be a "real doctor" etc, etc) that is much deeper and exerts a much stronger control over your thinking. To the exclusion of any new information.
And, of course, it's so much a part of you that you don't see it as a bias.   And other people (patients) don't know it's there, so they're at the mercy of your unexamined assumptions.
The solution is exhausting, and no one will like it: constant critical re-evaluation of your beliefs. Both the science (as much of it as there is) and countertransference. And, most importantly, long looks at your own identity. How did you come up with it? Because, in fact, you did.

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===== ====== ===== The Last Psychiatrist: Geodon slide deck post finished
and can be found here. If people like it and there's interest, I'll do a similar thing for other slide decks and promotional materials, and maybe put out a monthly email newsletter. Depends on how much interest/clicks/links it generates.

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===== ====== ===== The Last Psychiatrist: God's Cheat Code For Accuracy
One reason why not having fixed and predetermined identities may be useful to us.

I. The Wisdom Of Crowds

How many M&Ms are in the jar at the bar? Wrong. So are the other thirty people playing the game. No surprise, it's hard to guess. But take the median of the answers, and you'll find it is closer than most of the people's answers. Take the mean of the people's guesses, and it is even closer to the truth.

Unfortunately, you're a narcissist, incapable of truly connecting with others. You fake it, posture the right emotions at the right times but even to you it feels unreal, disconnected.   And so you find yourself alone, even if surrounded by others. You just don't feel close to anyone, even those you are obsessed with, even to ask them their guess. It's a shame. You really wanted some M&Ms

It hits you: why not simply make several guesses youself, and then average them together?   It's better than nothing, right?

Turns out, you are right: averaging multiple guesses increases accuracy. Not hugely-- averaging two guesses increases reliability by, say, 0.3%. Hey, it's not like it cost you anything.

II.

Yeah, but so what? Getting one other person's guess and averaging it with yours would have increased accuracy by 7%.   True, but you're too self-absorbed to ask her how many M&Ms she thinks are in there. Let alone to ask her out. (You think it's shyness. I know, I know.)

What you need is a way of obtaining an educated second opinion without actually involving other people. One way is to do this:

First, assume that your first estimate is off the mark. Second, think about a few reasons why that could be. Which assumptions and considerations could have been wrong? Third, what do these new considerations imply? Was the first estimate rather too high or too low? Fourth, based on this new perspective, make a second, alternative estimate.

This is called dialectical bootstrapping, and, provided you are not an idiot, it works. A recent study found that doing this improved accuracy over simply guessing twice and averaging the results:

I mention that you can't be an idiot because your guess has to be rationally considered. Simply guessing, or using some crazy worldview, is not likely to work.

But here's a question: why does averaging with some other idiot's guess still beat averaging with your best, most thought out second guess?

III.

The reason averaging two people's guesses improves accuracy has nothing to do with the accuracy of the guesses-- indeed, a moment's reflection shows that both people could be idiots, and the average still gets you closer to the truth:

---Guess 1--------Truth----------------------------Guess 2-----      (1)

The accuracy of two people's average is related instead to the qualitative differences in their errors. Two people do not make the same kinds of errors-- systematic errors-- and so averaging them will cancel those out. (In a simplified example: Bill tends to overestimate, John tends to underestimate. Now consider the numerous biases or cognitive heuristics that each person uses to make guesses, that may be negated by averaging.)

Averaging two of your own guesses reduces the random error-- so you get a small improvement-- but without additional information or reflection, you're likely to make the same kind of systematic error in your guesses.

Dialectical bootstrapping is a way of reducing both random and systematic error. In order for this to work, your second guess has to be a thoughtful one, using either more information or at least reflection from a different perspective. This different perspective has its own systematic error, but less of your first guess' systematic error. That's why averaging with this second guess can considerably improve accuracy.

But, as shown in the graph above, it's still less accurate than averaging some other idiot's guess precisely because that idiot is not you. There's a larger difference in your systematic errors and Bill's systematic errors than there is in yours and "yours from a different perspective."

If you follow this reasoning, then it suggests that God has included a Cheat Code to improving accuracy: pretend you are someone else.

IV. The Wisdom of Narcissism

Because narcissism is so dependent on the interplay between two people's personalities, narcissists are quite excellent, through natural inclination or diligent practice, at empathy. Granted, they might not care what the other person feels, but they are amazingly perceptive when they choose to be.

Everyone has narcissistic traits; the question is, how well can you tap into them?

In theory, people who are perfectly able to get inside another person's head-- or were completely able to get out of their own head-- could produce a second guess that would be totally independent of their first guess, and there'd be an increase in accuracy almost identical to actually asking another person. People who are less able to do this would get gains that were less. In other words, something like this:

IV. Is that really narcissism?

You might think my labeling of this trait as narcissistic is superfluous or exaggeration. But some teens hide behind irony; some people have excellent bullshit detectors; or the ability to "read" a person's body language; all of these things are really the ability to look into yourself and determine what those things would mean if you said or did them. And that works because that's how you learned to be a person in the first place: by incorporating various characteristics from other people into yourself. Healthy narcissism, self-aware narcissism, means you remember how and where those characteristics came from. "I've inherited my Dad's temper."   So if your Dad was really mad, how many M&Ms would he think were in there?

-----------

1. You might ask, but what if my two guesses are both on the same side of wrong?

--------------------------Truth-------Guess1--------------------------Guess2-----------

The average isn't more accurate.

However, in real life, you wouldn't know which of your two guesses was better. You'd have to pick between them. The average of the two guesses may be worse than one of the guesses, but it is always at least as good as randomly picking one of them.

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===== ====== ===== The Last Psychiatrist: Good Game, America

Way to play D. Let's get together and do this again next generation.

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===== ====== ===== The Last Psychiatrist: Gossip Girl Is Going To Corrupt Someone

please let it be me, please let it be me

The Parents Television Council does not like threesomes on TV. This is what they wrote in a letter to the network about the upcoming threesome episode of Gossip Girl:

Will you now be complicit in establishing a precedent and expectation that teenagers should engage in behaviors heretofore associated primarily with adult films?

Wow. Do you really think that this is the best choice of words to sway the makers of a show called Gossip Girl?

II.

I can understand worrying that menages are being mainstreamed-- "Parents worst nightmare!" But there's a bit of ignorance here: teens don't watch Gossip Girl, they watch The Hills. The median age of the CW network is 34. Gossip Girl draws 2-3M viewers, 84% are women over 18-54, average age 27. Believe me, they already know about threesomes, and at least eleven have been in one (p<.00001)

III.

That said, the PTC does have a valid point, made terribly. Barely five percent of the TVs that are on at that time are tuned to the show; in other words, very few people watch it. Yet there isn't anyone who doesn't know about it, even if it's imagined based on magazine covers. So the airing of a menage episode mainstreams it for people who don't watch the show, and that's actually more powerful a cultural influence. i.e. If you're a fan of the show, the threesome is specific: those three people are doing it. For everyone else not watching, it becomes background noise: "oh, people are having threesomes now..."

This is why it is true that even if you are not interested in pop culture, pop culture is interested in you.

IV.

Look back at the PTC's quote at the top: the overly formal syntax is a set up, it's an organizational chart. They're the parents, reprimanding the adolescent network "who should know better" than to do that to their little sister audience. Obviously the CW isn't going to buy it, so in order for this to have any power, it has to be made public.

Hence, this comes from a press release.

The PTC asks, I assume without intending any irony:

Finally, you must ask yourself, how does airing this program serve your obligation to serve the public interest?

If the PTC's obligation is to try and get sex off TV, how does releasing a press release angry about "promiscuous and consequence-free sexual behavior", days before the episode airs, serve the public interest? Doesn't it just make you program your DVR? The press release got picked up by the news agencies and now it's everywhere-- the only reason I know there is a menage episode coming up is because of this letter.

The network's own promotions talk about the program as a 'parent's worst nightmare.' How many 30-year olds care what their parents think? Zero. Only a teenager would be responsive to a parental 'forbidden fruit' marketing ploy like that, and CW knows it."
Do they not understand, or do they understand perfectly well, that their press release far more contributes to the mainstreaming of "risky behavior" than the show itself? It's a question of branding: since the PTC is out of touch, anything they hate must be good. Once a brand is established, anyone can use it any way they want:

The PTC needs to read its own mission statement. They're upset not simply that there's sex on TV, but that the TV makes that sex more acceptable to society. Ok, fine, but then they should not be in the business of censoring TV, but in influencing cultural norms to not want sex on TV.

In other words, they should be doing it quietly, applying direct pressure on networks so that if they obtain the desired outcome, it appears that it came naturally. Otherwise, it looks like you are suppressing something-- and people will look for it; or it appears self-aggrandizing.

I have no personal beef with the PTC, but I am observing that the PTC, like so many other groups pressing for change, deliberately take approaches that fail (and have repeatedly failed--"mind blowingly inappropriate" is from 2007) and thus ensure their own existence. Worse, not only are they not effective, but their self-referential publicity makes it difficult for another group to gather members in order to legitimately try to effect change. If the PTC really cared about stopping sex on TV, then, oddly, the best way for them to do it is to disband.

---
http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Grade Inflation

speculate on the use of a Tardis

Today we're going to talk about the causes of grade inflation. "Wait, is this going to be on the test?"

You're a professor and you grade the paper a C. The next day Type A Personality Only Child comes up on you, "how is this a C? I answered the question correctly, didn't I?" Yes, but you write like a nine year old, 80% of this is the syntactical equivalent of "umm" and "ahhh", and many of your sentences are minimally altered passages right from Wikipedia. "But this is a history class. Why are you grading my writing style?"

There's really no good way for a professor to respond to this nut. The depth of his stupidity precludes any explanation from being meaningful; he will not be able to understand that the writing is a reflection of the rigor of the ideas which is a reflection of the knowledge of the material and etc. So you give him an A and head to a strip bar. I sympathize.

Two explanations are commonly offered for grade inflation-- and let me clarify that the grade inflation people complain about is the kind that happens in the introductory survey courses. No one worries about grade inflation in the 400 level thermodynamics class. 1. Universities don't incentivize teaching, they incentivize research, so the teaching suffers. 2. Students are drunken idiots. While both have merit, let's see if there isn't another explanation that shrewdly protects the unconscious of most of the players..

II.

Here's a nice graph:

The only surprising thing to me about this graph is nothing. Since no one over 90 is reading this, let's focus on 1986. What happened in 1986 that changed the grading trend?

Generation X went to college, that's what. Coincidentally, psychological researchers Twenge et al found that that was the year narcissism on campus began to rise:

And by "coincidentally" I mean "not coincidentally." It's hard to tell a growing population of narcissists that their schoolwork blows, so you don't: A. Makes sense.

Most people stop their analysis right there, but you should really go the extra three steps and not just pee in the sink: now those students are 40. They grew up to be the Dumbest Generation of Narcissists In The History of the World, so narcissistic that not only are they dumb, but they do not know how dumb they are and cannot be told how dumb they are. They are aware that there are things they don't know, but they are certain that they have at least heard of everything that's worth knowing. Whenever the upper management guys at Chronicle Of Higher Education or The National Review pretend to disagree about the "classics" or "Great Books" or the "value of a liberal education," after five minutes it becomes clear that even they haven't read all those books, or most of them, or even a respectable minority, or three. They've read about them, ok, that's what America does, but when you finally pin them down and they admit they haven't read it-- which would be fine-- their final response is of the form "there's no point in reading Confessions now since we've all moved beyond that." Oh. And those are supposed to be the smart ones; everyone else in the generation thinks that the speed at which they can repeat the words they heard on TV or read on some magazine's website is evidence of their understanding.

II.

Which brings me to the main point, the other cause of grade inflation that no one ever talks about: in order for a grade to be inflated, a professor has to inflate it. In other words, grade inflation isn't the student's fault, it is the professor's fault. A kid can complain and whine/wine all he wants, but unless that professor buckles, there's no grade inflation. So the starting point has to be: why does a professor inflate a grade?

Yikes. Now that shudder you're feeling is not only why you never thought it, but how it is possible no one else ever brought it up? The answer is: every discussion about grade inflation has been dominated by educators.

The "college is a scam" train is one on which I'm all aboard, but that doesn't mean each individual professor has to be scamming students; there's no reason why he can't do a good job and teach his students something that they aren't going to get simply by reading the text. If a student can skip class and still ace the class, the kid is either very bright or the professor is utterly useless. Right? Either way, the kid's wasting his money.

And I know every generation thinks the one coming up after it is weaker and stupider, that's normal. But why would a professor who thinks college kids are dumb turn around and reward the King Of Beers with an A?

The answer is right in the chart and in a book by Allan Bloom that most college professors have read about. When that professor who was 40 in1986 was back in college in 1966, he was part of a culture that believed there are no "wrong answers, only wrong questions", like "you really think we should we stop shaving?" or "should we listen to something other than CCR?" And meanwhile the rate of As doubled. So now you have to put up your money: if you believe that grade inflation at that time masks/causes a real shallowness of intellect and education, then those students, now professors, simply aren't as smart as they think they are. Unless you also believe that bad 60s music and even worse pot somehow augmented their intellect.

And if you accept my thesis that narcissism prevents insight because it is urgently and vigorously self-protecting, then these same professors are not aware of their deficits. They think they know the material they are teaching simply because they are teaching it.

The problem is they are grading your papers and they do not know how to value a paper. Of course they can tell an A+ essay and they can tell an F- essay, but they are pretty foggy on everything in between. But they do not realize they are foggy. They think the problem is "the students complain." So they judge essays in comparison to others in the class or they fall back on the usual heuristics: page length, sentence complexity, and "looks like you put a lot of work into it."

And worse-- much worse, given that they are supposed to be educators-- they have no idea how to take a so-so student and make him better; what, specifically, they should get him to do, because they themselves were similarly mediocre students who got inflated As. Do you think they got their A in freshman analytic philosophy and said to themselves, "Jesus, I know I really didn't deserve this A, I better go back and try and relearn all this stuff." No: they went ahead and got jobs in academia, so that when a student comes to them asking, "how can I do better?" they can respond, "You need to apply yourself." Idiot. The system is broken. You broke it.

III.

Here's an example. Say your essay question is, "describe the causes of the American Civil War." Ok, so far everything the kid knows he learned from Prentice Hall, but something inside him thinks the answer is: LABOR COSTS. Hmmm. Insightful and unexpected, let's see what he does with it.

But there's not much he can do with it, there aren't many obvious resources to pursue this "feeling" he has. He does what he can. It's not that good. C. Grade inflation gives him a B.

Meanwhile, Balboa the el ed major searches carefully in his textbook and discovers the cause was... SLAVERY. He airlifts two sentences each out of five other books, asks for an extension because his grandmother died, adds nine hundred filler words including "for all intensive purposes" and "he could care less", and then waits in the parking lot to threaten you with "but this is a history class. Why are you grading my writing style?" He gets an A.

The problem is that the first kid is strongly disincentivized from pursuing his idea, from becoming a better thinker, in very specific ways.

First, and obviously, since the majority of the students are going to get an A, he just has to do just as well/horrifically as the average student, and if they're all writing about slavery with the enthusiasm of a photocopier then if he wants an A he better buckle down and learn the truly useful skill of masking the words of a Wikipedia page.

Second, he is very nervous about offering a professor anything that he didn't hear the professor explicitly mention, let alone endorse. What if it's "wrong?"

Third, because grading an essay is subjective, all professors try to make it objective by attributing value to measurable quantities which are actually stupid. For example: in most undergrad classes, the bibliography counts for 5%, maybe even 10%. How you (that's right, I said "how you") going to pad a bibliography with six sources when you can't even find one to support your thesis? So the pursuit of an interesting thesis is blocked by the 5% of the grade that comes from something that should count for exactly -20% of your grade, i.e. if you have a bibliography, you're a jerk.(1) This false value has two consequences: it "pads" the grade (e.g. the student already starts with an easy +5-30%) so it is easier for him to get an A. But more importantly, it is now easy for the professor to justify giving him an A. "His content wasn't that great, but the points added up; and besides: what the hell would I tell him to improve?"

I can't emphasize that last part enough-- the cause of the ridiculous grading is not the complaining of students but the convenience of the professor.

This is why if you are in a class and you feel the need to ask, "how many pages does this have to be?" and rather than look at you like you just just sneezed herpes on his face he instead has a ready answer, you are wasting your money. I get that you need the degree, I understand the system, but you're wasting your money nevertheless.

IV.

Take a quick scan of what these academics consider the highest level of academic scholarship: read their own journals. Here are the first three paragraphs of the first article ("Terrorism and The American Experience: A State Of The Field") in the temporally coincident month's Journal of American History, and I expect you to read none of them:

In 1970, just months before his death, the historian Richard Hofstadter called on U.S. historians to engage the subject of violence. For a generation, he wrote, the profession had ignored the issue, assuming that consensus rather than conflict had shaped the American past. By the late 1960s, with assassinations, riots, and violent crime at the forefront of national anxieties, that assumption was no longer tenable. Everywhere, Americans seemed to be thinking and talking about violence, except within the historical profession. Hofstadter urged historians to remedy their "inattention" and construct a history of violence that would speak to both the present and the past.1

Over the last four decades, the historical profession has responded to that challenge. Studies of racial conflict, territorial massacres, gendered violence, empire, crime and punishment, and war and memory make up some of the most esteemed books of the past generation. Yet on the subject of "terrorism," the form of violence that currently dominates American political discourse, historians have had comparatively little to say. Since the attacks of September 11, 2001, a handful of conferences have addressed historical aspects of terrorism, from its nineteenth-century origins to its impact on state building and national identity. Scholarly journals (including the Journal of American History) have devoted the occasional special issue to examining terrorism's roots and present-day implications. Within the historical profession, several book-length works have taken up episodes of terrorism, examining the production of both violence and state repression. Social scientists and journalists have offered sweeping global histories, tracing the problem of terrorism from antiquity to the present.2

As a result, we have a better understanding of terrorism's history than we did a decade ago, but it would be hard to classify this surge of work as a flourishing subfield or even a coherent historiography. Almost a decade out from 9/11, most U.S. historians remain hard-pressed to explain what terrorism is, how and when it began, or what its impact has been. There is little consensus about how best to approach the subject or even whether to address it at all. This is partly because the issue poses knotty political questions: How do we talk about terrorism without reinforcing the "war on terror" or lapsing into hopeless presentism? It also brings serious methodological problems: Is terrorism a word to be traced through centuries of semantic permutation? Is it an epithet to be applied to forms of violence we do not like? Is it a concept to be defined, however loosely, and followed through time?
Like any project that takes its cue from current affairs, constructing a historiography of terrorism requires caution and a light touch...

If a student wrote this I'd punch him in the bladder and get a good defense lawyer, assault charges be damned. I've deliberately avoided the easy targets like the po-mo journals; this is "the leading scholarly publication and the journal of record in the field of American history" and the author goes on like this for 20 pages. Can you trust this professor to grade an undergrad paper? The first two paragraphs are filler, meaningless noise in the guise of a sophisticated introduction. Maybe she can tell an A+ and she can tell an F-, I have no idea, but is she in any position to know a C from a B? And help you improve? Do you want to write like her? If you had questions about the history of terrorism, or terrorism, or history, would you call her?

I picked her because she was at random, but the same forces apply ubiquitously: academic journals are long, boring, poorly written academic-ese that no one reads because whatever insights or information they possess are buried in...the syntactical equivalent of "umms" and "ahhs." Even those who theoretically need journals to do their jobs every day (e.g. lawyers and doctors) avoid them.

Apart from boycotting any classes taught by these people I don't know what the solution is. Some professors cleverly include a "class participation" grade, and these professors pride themselves on using "the Socratic method." Sigh. Asking random students random questions is not the Socratic method, it's annoying, In order for it to be a true Socratic method, the professor would have to ask the student to state a thesis, get him to agree to a number of assumptions, and then masterfully show, through dialogue, how that agreement undermined his own thesis. In other words, the professor would have to have considerable fluency with his topic and be interested in each individual student, as an individual. Good luck with that. (2)

V.

If you reconsider grade inflation not as a function of the quality of the output but rather as the result of a hesitating lack of confidence about what constitutes good quality-- and again, I'm talking not about A+ and F- but the differences between the B and C levels where most "good" students are; and accept that, simply as a numerical reality, these "average" students are then the ones who (likely with the assistance of grade inflation) go on to become future academics, then a number of phenomena suddenly make a lot of sense. And the most important one is the one that students have long suspected but never dared say out loud: professors do not know the material they are teaching, but they think they do.

An American History professor may be considered somewhat of an expert because he's been teaching the Civil War for the past 15 years, but he's only been repeating what he knew 15 years ago for 15 years. And every year he forgets a little. How carefully is he keeping up with it-- especially if his "research interests" happen to lie elsewhere?

I know doctors who have been giving the same receptor pharmacology lectures to students for a decade. I know they are narcissists, not just because they are too apathetic to keep up with the field, but because it never occurred to them that receptor pharmacology might have advanced in ten years. They believe that what they knew ten years ago is enough. They are bigger than the science. These aren't just some lazy doctors in community practice, these are Ivy League physicians responsible for educating new doctors with new information. Yet the Power Point slides say 2001. "Well, I'm just teaching them the basics." How do you know those are still the basics? Who did you ask?

You think you philosophy professor re-reads Kant every year? The last time he did was in graduate school-- when his brain was made of graduate student and beer. Think about this. Hecko, has he even lately read about Kant? Do you think he tries, just to stay sharp, to take a current event and see what Kant might say about it? No, same notes on a yellow legal pad from Reagan II. Does he "know" Kant because he's been "teaching Kant" for 20 years? When in his life is he "challenged" by someone else who "knows" Kant? Seriously, think about this. For two decades the hardest questions he's been asked come from students, and he's been able to handle them like a Jedi. How could he not think of himself as an expert?

The sclerosis of imagination and intellect that inevitably happens over time will make it impossible for him to grade a paper that does not conform to his expectations. I don't mean it agrees with the professor, I mean his expectations of what a good paper looks like. Students already have a phrase for this: "What he likes to see in the paper is..."

So when it comes time to write a paper about Kant, it is infinitely less important that he understand Kant then it is for him to understand what the professor thinks is important about Kant-- and it is way easier to get through college this way. And if you have the misfortune of being taught Kant by a guy whose "research interests" are not Kant, forget it. You're getting an A, and he hates you.

VI.

This stuff matters, it has real consequences. When one narcissistic generation sets up the pieces for the next generation, and you put the rooks in the middle and leave out the bishops and hide one of the knights, and then you tell the kids that they lack the intelligence or concentration to really learn chess, you have to figure they're not going to want to pay for your Social Security. Just a thought.

Also: TAs are helping grade some of the papers, and some is worse than all. In order to ensure grading consistency, the essay answer has to be structured in a format that facilitates grading-- because if the professor can't value a B form a C, how can a TA? So the answer must mirror the six points in the textbook or the four things mentioned in class. This, again, means you shouldn't spend any time learning, you should spend it gaming the essay.    So if the essay question is, "Discuss some of the causes of the Iraq War" you can be dead sure that "some" means specifically the ones the professor thinks are important. There may be others, but you're taking a big risk mentioning them. The TAs are just scanning for keywords. As long as they're in there, even in grammatically impossible constructions, you win. A. (3)

VII.

Here's one solution: abandon grades.

"But we have to have some way of objectively evaluating students!"

Haven't you been listening? You can't just suck the Red Pill like a Jolly Rancher, you have to swallow it. Grades aren't objectively measuring people, the whole thing is a farce. The grades are meaningless. Not only do they not measure anything, but the manner in which they are inflated precludes real learning. Stop it.

"Some grades aren't inflated." But how would anyone on the outside know? Can you tell them apart? The long term result will be: bad money drives out good money.

"Well, I earned my As." No you didn't, that's the point. I'm not saying you're not smart or didn't work hard, I'm saying you have no idea how good or bad you are, you only think you do.

"Just pass/fail? But how will employers know a good student from a bad student?" Again, you are avoiding the terrible, awful truth because it is too terrible and too awful: when employers look at a GPA, they don't know anything. The 3.5 they are looking at is information bias, it not only contains no information, it deludes you into thinking you possess information. You can't erase that 3.7 from your mind. In what classes, in what levels, against what curve? Just because employers do it doesn't mean it's useful. They use sexual harassment videos, too.

Grades do not only offer incorrect evaluations of a student's knowledge, they perpetuate the fiction that professors are able to evaluate. They can't. Again, they may be able to tell an A+ and an F-, but a B+ from a B? Really? That's the level of their precision? But a professor cannot ever admit that he doesn't have that precision, because it cannot enter his consciousness that he doesn't. "I've been teaching this class for 15 years."   And I'm sure it gets easier every year.

VIII.

Speaking of Iraq: on the eve of the Iraq War many Americans got together to demonstrate. I'm not in the protest demographic, the only way I'm going to be at a march is if there's alcohol, but I accept the fact that a protest is sometimes the only way to be heard and the last resort against a government that has forsaken you. I get it. Ok. So I'm watching the protests on TV, and a lot of people quite obviously don't want to go to war, and want it stopped at all costs. And I see a group of people with signs walking behind a long banner, and the signs and the banner say, basically, "UNIVERSITY PROFESSORS AGAINST THE WAR."

I've no doubt that there wasn't a little bit of the old Vietnam nostalgia there, but what made me furious was the signs. They actually believed that identifying themselves as university professors was helping the cause? Did they think Americans were going to slap their foreheads, "wow, educated people are against the war, maybe I gots to rethinks this?" Yes, that is exactly what they thought.

They could not see that they were sabotaging their own cause, that anyone ambivalent about Iraq would either not think anything or be blinded by white rage, "look at these mother--" and vote for Bush six more times. These professors were coming from such a profoundly narcissistic stance that they didn't see this, or they didn't care. They may have wanted to stop the war, but what was much, much, much, much, much more important was to be identified as against the war, even if by doing that they were causing other people to support the war.

Here's what TV didn't show: the next day, those professors went to their classes, taught a bunch of anxious, restless but bored students stuff that they really had no business teaching, and later asked them to write essays that could be graded essentially as multiple choice questions so that they wouldn't really have to read them. If these professors didn't realize or care that that they were violating their own principles about war merely to self-identify, do you think they care about you? They have much bigger things to worry about. A.

---
1. Bibliography, as distinct from references. Anyone who produces a Bibliography without specific references as some sort of support of the truth of their idiocy is on notice. I'm talking to you, DSM.

2. An interesting educational experiment would be to come at things form a negative perspective. "Look, class, Hegel was a complete jerk, and his ideas were infantile pseudo-buddhism garbage. I'll give 50 points and a candy bar to anyone who can explain to me why." And see if that doesn't inspire the student to want to understand what Hegel was trying to say. I don't know if this will work. I know that a disengaged professor saying that Hegel is a great German philosopher and then reading lecture notes written back in 1986 on a yellow legal pad very clearly doesn't work.

3. Here's an essay I'd love to read, hell, love to write: "There are numerous "established" causes of the Iraq War, yet they almost always cite reasons that occurred after 1990. Please watch the 1975 film Three Days of The Condor. Other than a Tardis, what explanations could there be for director Sydney Pollack's ability to predict the future with such accuracy? Please discuss some of the events of the late 1960s to early 1970s that made the finale's prediction possible."

---

Also: Here is precisely one of these professors

===== ====== ===== The Last Psychiatrist: This Week On Grey's Anatomy The Preposterous Happens
Previously heterosexual Callie becomes involved in a relationship with a female doctor, Erica. But when they "do it," as Callie later describes to Mark Sloan, she didn't like it.

"It was not good at all. I choked, I just couldn't go down there, I tried, but it felt so weird..."

[Mark gets up and leaves. Where is he going?]

"Two girls getting nasty and loving it; that's hot. One girl talking about how much it sucked, it's depressing. And wrong. Just wrong."

That's supposed to represent the "typical guy" response-- straightforward, basic.

Meanwhile Callie doubts her bisexuality, and thinks this was a mistake, and avoids Erica-- she's thinking she's doesn't like being with women after all.

Well thank God for self-awareness: by the end of the next commercial cycle she has the insight that what's bothering her is that she isn't good at giving oral sex. "I like to be good at things. I do not fail, I do not quit, I like to be good at things, and I want to be good at this, too." Get it? She wants to please her mate, but can't-- and this has thrown her whole identity into question.

You'll also observe, however, that how Callie felt about receiving oral sex from Erica is not even mentioned, at all. It doesn't matter. She's giving up on being with women not because she doesn't like it-- who even knows?-- but because she isn't technically adept at performing oral sex. Callie feelings don't matter to Callie, Erica's perception of Callie matters to Callie. This is narcissism masquerading as sexual altruism.

As if to reinforce my point, Callie, now understanding the problem, identifies a solution: she asks Mark to teach her. No, I'm not kidding. And she actually uses these words: "just because you didn't publish a big clinical trial, doesn't mean you're not a genius."

I think this even offends me. Can you imagine if Callie was involved with a new guy, and she goes to Mark and says, "look, I tried to give that guy a blowjob, but I failed, and I don't fail. Will you let me practice on you?"

My first thought was that this discounts the gay relationship, but it really discounts sex itself, it uncouples sex from any intimacy or even pleasure at all. Look, I'm not romantic, if there's casual sex to be had, you can be sure I'm hiding behind the couch watching it, but this isn't about Callie's freedom to use her sex as she wants; this preposterousness is actually supposed to not affect Erica; strike that, the deluded nutjobs watching this show are supposed to accept that within the context of the show, she's doing it for Erica's benefit!

When he agrees, she is ecstatic-- "oh my God, really?! Thank you, thank you!" NB: this isn't what she says after the sex, this is what she says in anticipation of learning how to do it.  Note again, whether or not she is actually bisexual-- i.e. likes sex with women-- isn't relevant; she wants it only if she's good at it, and doesn't want it if she isn't good at it.    It's this same process that goes into the recent phenomenon of men who want to have sex less than their wives.

II.

It's old news that TV dramas are shows about narcissism-- that's what the viewers want-- but the only way to make that ego greed permissible is to make the characters do something noble once in a while, appear altruistic. Hence the popularity of doctor and lawyer dramas. And these characters always seem to get emotionally involved with their patients-- which wouldn't be possible if they were narcissists-- except it is, because they're not involved with the patient, they're involved with the patient as proxy for something going on in their own lives.

One of the worst things about Grey's Anatomy is how manipulative it is-- it tells you what to feel, and it never occurs to you that you're being lied to.

Here's an example: in that same episode, Yang-- who I believe plays the part of a schizophrenic woman pretending to be a surgeon-- performs a kidney transplant on a man who is getting the kidney from his mistress; she's giving it because she thinks he will then leave his wife and be with her.   After the surgery, the woman is lying in bed complaining-- "Why isn't he coming to see me? He needs to come down here and face me, and make a choice between me and his wife!" And Yang, firmly but compassionately, says, "he hasn't asked for you, or called. I think he's made his choice." And the woman breaks down crying, realizing that she can't get a man by giving him a kidney.

It's supposed to be an example of the noble, straight-talking Yang, at her best, words used with surgical precision. But why didn't this idiot have this conversation with the woman before the surgery? More importantly, why doesn't it occur to the viewers that a real doctor-- which is why I suspect that Yang is not a real doctor on the show-- would have tried to prevent this gigantically unethical situation in the first place? Because then there's no chance to show Yang's identity. Because it's not about making right decisions, it's about appearing a certain way.

As evidence for this, the surgery squad does confront an ethical transplant dilemma head on: a father wants to pay his son $10000 for his kidney. It's funny, and by funny I mean I'm moving to Russia, that manipulation with money is bad, but manipulation with emotions isn't even considered to be manipulation. It's business as usual.

III.

You take issue, perhaps, with my characterization of TV dramas as narcissism. You say, well, they're surgeons, of course they're going to be narcissists. You're confused, you think the narcissism is a consequence of it being a show about surgeons; but that's backwards, the characters as surgeons is the consequence of it being a show about narcissists. Narcissism is the point. That's what the viewers want, not surgeons specifically. To make stories about narcissists believable, you then use surgeons, not, say, endocrinologists. You need to be able to make a scene where two doctors are dating-- they are actually living together-- but he leaves her name off a major publication because,

"you're don't deserve it, you're a baby, you have the potential to be a great surgeon, but you have a lot to learn."

And the way to do that is to make them surgeons. So that it confuses the viewer just enough to say, "yeah, I guess that's a plausible way for a couple who recently moved in together to talk.

So that in the next scene, viewers do not think it preposterous that the female character accept the correctness of that criticism, and wallow in self-doubt.

Median age of Grey's viewers is 46. You'd think they'd know better. Or not.

------

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===== ====== ===== The Last Psychiatrist: Guess What Isn't The Cause Of Physician Suicide
Don't worry, the word narcissism does not appear in this post.

A review article in Psychiatry finds that the suicide rate among physicians is higher than the general population. What's interesting about the article is what they don't find.

What they do find is that the male rate is lower than the general population, but the female physician rate is not only higher than the general population, it is even than the male rate.

Why? Cultural bias might suggest women would be happy to have advanced to the level of doctors; though that same bias, read the other way, might suggest that the unrealistic expectations of how awesome it is to be a doctor meeting the reality might drive them to suicide.   Speculation, your Honor.

The article then explored causes for physician suicide, and this is where it got interesting. The article cites a number of reasons: role conflicts, career dissatisfaction, personality stylings, morale-- all the possibilities even a layman might suggest.

But these aren't laymen, they're psychiatrists. What the psychiatrists do not point to as a cause is psychiatric illness.

In any study about suicide, psychiatric illness, depression, bipolar, etc, is the main cause, if not the only cause, cited. Axis I pathology is the framework for interpreting the rates, as well as deciding what to do about it.    Not "life got him depressed," but "he had depression." Not "lifestyle modifications, religion, family" but "there are a number of treatments available."

But in this article, only one paragraph is given to Axis I disorders.

As an example of the prevalence of depression among physicians, according to a 2006 survey by the American College of Physician Executives, over two-thirds of responding physicians reported burn-out and nearly a third acknowledged current depression.

Biologic predisposition need not be involved.

The only Axis I pathology noted with any assuredness is alcohol abuse, but not as an independent diathesis for abuse, but as an outward expression of the distress.

As with suicide in the general population, in addition to depression, alcohol and substance abuse are common factors associated with physician suicides.[16,23] Alcohol and/or substance usage affect anywhere from 20 to 40 percent of physician suicide completers.

The article cites the ten (1) studies on this topic published since 1973. None of them cite psychiatric illness as the major cause; social explanations figure more prominently than biologic ones.

Indeed, even the title of this study belittles a psychiatric or endogenous cause: "Physician Suicide: A Fleeting Moment of Despair."

II.

I don't disagree with their analysis, but it's funny/scary to see the very people who are biased towards the organic model basically disavow the link when it applies to themselves.

Given the current climate of healthcare and the seemingly unending stressors in the practice of medicine, we physicians must be mindful of ourselves and our colleagues. We need to be sensitive to psychological distress in ourselves and others and be willing to obtain and offer support when needed.
But what about an SSRI? The need for an adjunctive "mood stabilization from below?"

In many cases, the suicidal impulse is a temporary phenomenon--one that will pass. We must be on guard not to lose ourselves or talented colleagues in a fleeting moment of despair.
When was the last time you heard a psychiatrist suggest that suicidality was temporary or transient? Why assume our colleagues are talented?

It appears to this blogger that when psychiatry has little direct information about the social factors impacting a group's lives-- for example, college students in China-- psychiatric explanations are held as paramount. When they are intimately familiar with the group, they lose perspective.

This is, essentially, the fundamental attribution error. We interpret the behavior of other people as the result of something about them (jerk, meanie, idiot), but we'd interpret the exact same behavior of ourselves as the result of circumstance.

Psychiatrists are assuming doctors attempt suicide in reaction to situations; but assume that others that they don't really know attempt suicide as a result of something about them.

The key is the italicized part; the more you know of a person, the more likely you are to blame circumstance. The less you know of a person, the more likely you are to blame them.   The question is which of those two is the error-- not knowing enough about another's circumstance, or not being able to step back and see ourselves from the outside, for who we are?

There's a term for the latter, but I cannot remember what it is.

------------------

1. Three examples of the cited studies:

Petersen's study (2008) of 1984 through 1992 from 26 states, and looking only at whites, finding 181 male and 22 female doctors/dentists who suicided, the word "depression" does not even appear at all. Neither does Axis, etc.

Scherhammer's study of rates (2004): "depression" appears only twice.

Aasland's study (2001) found that being married is protective; but summarily dismissed the link to psychopathology with that depression and drug abuse are the most common psychiatric illnesses found in doctors, but that most people who are able to become doctors probably don't have serious psychopathology. Ok-- so suicide isn't a marker for psychopathology?

In Hem's study (2005) only three sentences are given to the possibility of a psychiatric illness; and then it is explicitly minimized: "However, there may be specific reasons [why doctors commit suicide.]" The study cites over a dozen: stress, long hours, access to lethal medications, etc.

More than 60 different risk factors for suicide have been described. Thus, suicide is a multi-determined event, and the search for a single explanatory factor is too simplistic.

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===== ====== ===== The Last Psychiatrist: Guess What Is Unstoppable: Movie Review

i probably saw a different movie than you

The plot of Unstoppable is deceptively simple: an unmanned freight train is accidentally sent running down the track, hurtling with all the force of an unmanned freight train towards a small town in Pennsylvania, where it will derail at a curve like an unmanned freight train and destroy the earth. Two men, Denzel Washington and Chris Pine, risk their lives to bring it to a safe stop.

True to the title, the train is unstoppable. It defies its brakes, it blasts through an RV, it flips over several police cars, it flips a train in front of it which then explodes with the blast of the Manhattan Project, ignores a SWAT team shooting assault rifles at it (really) and not only rides right over the Automatic Derailers, it shoots them off the tracks where they take out some more police cars.

What no one initially realizes is that not only is the train 150 miles long and carrying AIDS, but it is also a Decepticon.

Here's a movie tip: whenever they apply personification to an object, then that object itself stands for something else that isn't a person. In this case the train, like zombies, is a metaphor for cold, uncaring, unstoppable, raging capitalism, and as soon as I say that the rest of the movie makes complete sense, i.e. makes no sense at all. The movie then gets retitled, Unwatchable.

II.

This is what happens in the movie:

A dumb, fat, lazy white guy-- none of those are insults but deliberately highlighted aspects of the character-- made a series of errors: didn't follow protocol, didn't listen to
his superiors, took shortcuts, all which lead to the train taking off at full throttle. Fattastic's immediate response is to chase it, on foot. Fail.

It hurtles towards a small town called Stanton, PA, home of All That Is Good In This World. Who can save this small town of hard working folk from the evils of capitalism? Not middle aged white guys, that's for sure, they got us into this mess. No, the main good guy at HQ is a young non-white woman, Rosario Dawson, who I'm not sure is qualified to be an actress let alone in charge of a railroad. But there she is, the voice of reason, a tough-as-nails mix of pragmatism and ethics, surrounded by Corporate White Guys who only care about the bottom line.

This scene actually happened: a bunch of Corporate White Guys are sitting around a conference table trying to figure out how to stop the train with minimal damage to the company.   Finally, they call the Big Boss who isn't physically present on site during this disaster and can't be bothered to show up. You'll never believe where he is. A golf course. I know. The Suits tell him that the train has the potential to destroy reality as we know it, should they derail it? and because he is a Decider he only needs to ask one question and that question is, "what will the effect on the share price be?" I didn't know that that was something you could get a definitive answer to? But I'm not white.

After the White Guys have tried everything else-- in other words, have made no real attempt slow Capitalism down, the actual job of saving the Earth falls to... wait for it... an older black man and a very young white man-- his apprentice. They young white guy actually comes from a powerful family and they pulled strings to make him the conductor. The message is clear: the middle aged white guys have wrecked everything, the future belongs to the young white guys coming up but they don't know anything because they come from privilege, i.e. older white guys; and the only practical knowledge left is possessed by the hard working black men upon whose back the white guys built everything. Hopefully the Denzels can pass their knowledge along to the Chrises quickly, because of course Corporate will be laying the Denzels off to replace them with Chrises, which, we learned, is precisely what has happened to Denzel.   And if you think I'm exaggerating this point, the only other black person in the whole movie is the schoolteacher. Who will no doubt be laid off, just after she teaches all the white kids how to read and vote for Mitt Romney.
III.
No surprise: they eventually stop the train. But there's a completely unnecessary scene where they explain the plan.
The heroes/The Federal Reserve have a plan: chasing down Capitalism (from behind) in their engine, linking up, and then braking the whole thing to a halt.

A federal regulator, who at the beginning of the movie is ignored and marginalized, who only accidentally happens to be at HQ that day, disagrees:

INSPECTOR: I know the conventional wisdom is just link up and then throw the whole thing into reverse, but you'll get better traction if you alternate between braking and full throttle.

DENZEL: You sure about that?

INSPECTOR: Well, it's based on some preliminary calculations...

Get it? Capitalism can be saved by interspersing braking with stimulus! Wow.

IV.
The end of the movie is right out of a Lenin comic book. The white guy is injured, so the black guy has to stop the train himself, and heroically runs from the Last Car Of The American Economy all the way to the front-- but the last jump is too big.   "I can't do it," he says.

So it's up to the young white guy, heir to the future but injured in the present, to jump from a moving pickup truck back on to the Engine of Capitalism and bring it under control. Which he does, yay.   If the movie ended there it could be considered class warfare propaganda suitable for the Cubans.

But then the movie takes a decidedly bizarre, American, turn. The final scene is a press conference-- because the press always gets the final word about the resolution of a conflict and decide who's to blame and who's a hero. As the proletariat heroes answer questions for the thankful public, Denzel then explains to Chris how Corporate called and thanked him, and gave him and Chris promotions.   And then... that's it. End of movie.   No morality lesson, no one gets punished, everybody back to work. Once the runaway train of Inflation And Catastrophe is stopped, it is returned to its Corporate owners and filled back up with plutonium and baby souls.

Cut to camera 5, and pull back: to reveal that you are seeing this all on a TV screen, you realize that you are watching all of this on the news; in fact, you recall that the entire movie has been saturated with reporters giving exposition, TV screens with FOX or CNN showing us what happens. What we know-- the facts of the train's movements, etc, all come from the news:

Which is, after all, just like real life.

V.
It's a legitimate question we all first voiced in 5th grade: did the writer really have all that in mind when he wrote this? Maybe, maybe not, and I could also cop out by saying that the movie's accidental theme may be what resonated with an exasperated public, and thus makes it popular.

The problem with doing movie-as-social criticism is not that it reads too much into things but that it never goes to the inevitable conclusion. If that train is rampant capitalism, then it was human error that caused the trouble. None of this would have happened if it was all automated. Drawing only from the text, the problem isn't that we need more ethical people, the problem is we need less people all together. I'm not sure that's not the message they were hoping for.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Happy Fourth Of July

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===== ====== ===== The Last Psychiatrist: Happy New Year 2011 From Your Friendly Neighborhood Pirate

uncovering reality a little bit at a time

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===== ====== ===== The Last Psychiatrist: Has Anyone Noticed That Price Of Gold And Platinum Is The Same?
For the first time in history, the price of gold and platinum are almost exactly the same. Think about that. This has never happened before, ever.

Put another way: you have some gold, and you can trade it in for the same weight in platinum.

I don't know if that's bearish for gold (it goes to $500) or superbullish for platinum (back to $1580) but it is clearly a situation which cannot last. Plan accordingly.

Platinum has almost always been at least double the price of gold, or at least $400 higher. Fewer catalytic converters? Russian releasing their reserves?
===== ====== ===== The Last Psychiatrist: Healthcare Reform Is About Protecting Monopolies

Andrew Lawrence predicted it would be completed at exactly the right time, whenever that was

Brain teaser:

A Medicare patient comes to a Los Angeles psychiatric clinic for a new psych eval. 45 minutes later, the doctor codes and bills it as "90801 Psychiatric Diagnostic Interview" for $169, fee set by the government.

A month later, the patient returns for a 15 minute med check; the doc codes it as 90862 and bills for $61.

Question: if this appears to be a consistent reimbursement rate of about $4/minute, why are there two codes? Why not just bill Medicare by the minute?

II.

Most people assume the codes are simply government bureaucracy, like penal codes or social security numbers, the numbers are for public use. They aren't. They are a product, they are intellectual property. To use them, you have to license them. They are no different than a Jay-Z song: you have to pay Jay-Z for the right to use it.

The trick is that doctors have no choice, Medicare requires them to use these codes-- that they must first license or buy.

Who owns them? You probably think it's the government, but it isn't: it's the American Medical Association.

In 2001 they made about $70M from those fees. Trent Lott attempted (read: pretended) to try to break this monopoly, but 6 months later the Towers came down and no one needed to (pretend to) do anything after that.

At that time (and now) politicians assumed that the AMA wanted the copyright protection to help doctors, because it prevented the consumer from comparing prices:

The AMA has been able to impose on the entire nation the AMA's obviously self-interested policy against consumers comparison shopping for medical care based on price by suing Web sites and others to prohibit them from posting comparisons of doctor and other medical fees on the Internet using the CPT code [said Trent Lott]
And that sounds sufficiently populist to get support. But it's about doctors. It's about the business enterprise that is the AMA. It makes $70M from the CPT fees, but it makes only half of that from membership dues. In fact, most doctors don't even belong to the AMA (I don't, nor to the APA); it's only about 15% of doctors.

The AMA is in the healthcare business, but the business of healthcare is business.

III.

Lott was completely wrong, he was seeing the AMA as a proxy and protector of the greedy doctors it serves. Wrong. The AMA isn't going to protect reimbursement rates from Congress, but you can be sure it will protect CPT codes. $70M might not seem like a lot, especially in comparison to the money at stake in healthcare reform; but $70M is a lot to the AMA.

At some point in the growth of any organization, it spends increasing resources on its own existence. It's not because it is evil or selfish, it is by necessity. Consider the hypothetical example that the AMA wants to serve doctors, but membership is declining, so to boost revenue in order to serve doctors it tightens its grip on CPT codes, journal fees, etc. However, doing these things puts it further at odds with doctors that they want to serve, resulting in further declining membership, which, by necessity, results in even tighter grips, etc.

This is not an ethical judgment, it's public choice theory, it's survival. So far no problem. This is the important part:

At some later point in the growth of an organization, as the members become more vocal in their disapproval, it begins to question the sanity of its own members; it doubts whether the people it serves even know what's good for them.   It assumes that the self-interest of the individual members is morally inferior to the self-interest of the organization.

This point is an inflection point; it is the beginning of the end for one of them.

---
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===== ====== ===== The Last Psychiatrist: Healthcare Savings Accounts: Emphasis on Savings, Not Healthcare

A Healthcare Savings Account allows you to put aside $2700/yr, or $5040/yr/family, tax-free, for healthcare expenses. So what? So sit down.
First, a primer on deductible medical expenses. The IRS allows you to deduct the amount you spent on approved healthcare, minus 7.5% of your gross adjusted income. In other words, take your gross adjusted income (i.e. how much you make minus deductions) and multiply by .075. Subtract this amount from your total medical expenses: that's how much you can deduct.
You make $100,000. You incurred $4000 in medical expenses.
0.075 x 100000 = 7500. 7500-4000=3500. You can deduct 3500 from your taxes.
In the above example, if you only incurred $2000 in medical expenses, you can't deduct anything. Think of the 7.5% as a sort of-- deductible.
Healthcare Savings Accounts are different, and complementary. In the above example, the $4000 of medical expenses was (hopefully) made with money you earned and paid taxes on. If you're in a 35% tax bracket, you actually had to make $5400 to come up with that $4000. So you had to pay $1900 in taxes; and another $500 is a wash (7.5% deductible). So your illness cost you $1900 in addition to whatever the actual medical care cost.
But in George Bush's America, not only can you deduct medical expenses, but you can also put away money tax free for use in healthcare.
Many progressive types will complain that this doesn't solve the healthcare crisis, and they are right. But that's because HSA aren't about healthcare, they are about savings; they are another way of sheltering income from taxes. What they are, in effect, is 401(k)s.
Say you retire. You'll draw on your 401(k), which was funded by $14000/yr contributions, to pay for food, vacations, cable, whatever-- and healthcare. With an HSA, you can save $14000 AND $2700 a year, and use it as necessary when you retire. If you have medical expenses, you can just use the HSA money; the 401(k) money is for everything else.
So you can now save $16700 a year. AND you can deduct your medical expenses (above 7.5%)
And by the way, money in an HSA is fully investible, like a 401(k).
But what happens if you get hit by a truck (i.e. you have catastrophic medical expenses?)
Each HSA is linked with a "High Deductible Health Plan" (HDHP). They have high yearly deductibles of $1k-$2k, depending on the plan (which you can use saved HSA money to pay) but have maximum deductibles of about $5000 (or $10,000 per family.) In other words, you always have to pay at least $1000, but not ever more than $5000.

Each plan also has a monthly premium you have to pay (around $90) but about 60% is placed into your HSA (called "Premium Pass Through"-- you are in essence paying money to yourself, and the rest to the plan.) Each plan has different premiums, minimum and maximum deductibles, and penalties/enticements to use network services. These are summarized here, and in slightly more detail here.
Look, you can argue the social policy ramifications of this all day. But don't look a gift horse in the mouth.
By the way, you may be fascinated to know what is an allowable medical deduction.
Abortions
Acupuncture
Home improvements for health reasons (elevators, widening a doorway,"lowering" kitchen cabinets)
Fertility enhancement
Lead paint removal
Legal fees to get healthcare
Medical conferences and transportation (if the conference is about your/your family's illness)
Psychoanalysis
Transportation to healthcare services (gas, bus, etc)
Weight loss programs
Wigs
Vasectomies

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===== ====== ===== The Last Psychiatrist: Heidi's Real Problem On The Hills: She's In The Wrong Movie
I can no longer find the link, but someone-- Us Magazine? Entertainment Weekly?-- did a Most Memorable TV Moments, and the season 3 finale of The Hills was one of them.

They were right.

I realize this is a scripted show, not "real" (whatever that means anymore) but for illustration's sake let's pretend it''s a documentary.

By the end of Season 3, Spencer and Heidi have had a series of fights, while simultaneously she gets a job offer from casino mogul Sam Nazarian in Las Vegas to be a project director (of something.) She packs up and leaves in two days flat, and doesn't tell Spencer.

Spencer, meanwhile gets kicked out of his apartment for being controlling (and dirty), and slithers over to Heidi's. She's gone. He waits all night-- nothing. He freaks out, and finally his sister (Stephanie) discloses Heidi moved to Vegas. What?! He goes after her.

When Spencer learns she's at the Palazzo working over drinks, he speeds toward the posh hotel.

Abandoning Stephanie at the valet, Spencer strolls into the club and straight to Heidi's table. Interrupting her business dinner, he tells Heidi he needs a moment outside and walks away. Clearly mortified, Heidi begins to lay into Spencer and reams him out for disrupting her during what is clearly an important meeting with her employers.
I've so far seen a season and a half of The Hills (it is strangely compelling television), which I mention as support for my opinion that Spencer is a classic narcissist (though some leeway allowed because he is young.)

In the argument that ensues, Heidi identifies many of the traits: it's always about him, he wants to be with her when he wants, and then leave when he wants, etc.

And he inadvertently lists some of his character flaws himself, though of course he thinks he is being romantic:

I can't have you living in Las Vegas with how we ended things...
If it was really about missing her, it would be living in Vegas that would bother him, but it's not. The second part is the one that matters: the way they ended didn't involve him. She up and left, in two days, no warning, no message. She didn't break up with him (so that in his mind: cue music, cue dramatic long distance shot, and then pan back to his reaction); she simply dropped right out of his movie. That's what hurts a narcissist.

(What you're looking for here is not evidence that Spencer thinks he is the greatest guy on earth, but evidence that he thinks everyone is merely supporting cast in his movie.)

Spencer thinks nothing of interrupting her important meeting, in front of her bosses, making her publicly have to choose him over them.   That it's her job he's messing with, that this conversation can very easily wait until tomorrow or an hour from now never occurs to him, not because he is stupid but because it's important to him now, so it must be objectively important period.

Narcissism is not egomania: he isn't sure this is going to work. It is entirely possible that she might reject him-- he isn't in denial about this. But that she wouldn't be compelled to talk to him, or yell at him-- to have an interaction with him-- that's impossible. After all we've been through...

Pay attention, I'm going to give you gold: don't get fooled, like so many women do, that this has anything to do with getting her back. There is only one reason he made this trip:

"This (meeting) is really important, and obviously you don't care enough to respect that," Heidi says. "What are you doing?"

"I need to talk to you...."

That's not a lead in, that's the whole reason.

For narcissists, outcomes are irrelevant-- process is what matters. Getting her back is way less important than being connected to her-- sorry, her being connected to him-- whatever the form: love, hate, fear. It's all good.

I sense you are drifting to sleep. I'll repeat it: getting her back isn't the goal. He doesn't really love you, he just wants you in his movie.

We could ask, what would happen if Heidi didn't get up from the table to talk to him? He'd make a scene, of course. He'd yell and scream he loves her as the cops drag him away and taser him. If he makes a scene and gets taken out, he still wins, because he reactivated their "connection." And if nothing else, he's the one who gets to decide how it ends. He decides what emotions she leaves with, he decides how she remembers him.

NB: this is why suicide is the narcissist's trump card.

It's helpful to look at the relationship from the perspective of neutral observers. What do her bosses think while this is going on? Not, "I know this is important, go ahead, talk to him." Not, "this guy is extremely destructive, evil, get away from him." They think this, and only this: "umm, can this nonsense wait?"

That's the limits on narcissism's power: it only has the potential to work on those you aim it at. Other people don't share the worldview that they are simply bit players in your universe-- and so their attitude is to dismiss you. You don't count. Letterman once did an interview with Spencer that can be summarized: "who is this dope, again?" Spencer can't con Letterman into thinking he is who he wants to be.

(Hence the popular narcissist mantra: when I make it big, when I get discovered, then all these people will acknowledge me.)

And since he can't, he doesn't try to. Letterman isn't going to be in Spencer's movie, so Spencer doesn't really build a role for him.

But the direct target of a narcissist's powers can't do that, once the narcissist lures them into his movie, they're stuck because they become convinced that his movie is the only movie. Again, they don't have to play the part the narcissist wants, they don't have to like the guy, but they must operate within his movie that they now accept as their own.

It's easy and popular to blame Heidi for being vapid, but she can't be entirely stupid-- three men thought her at least capable enough to fly her out to Vegas and make her the project director. Nor is she necessarily a needy, empty, gullible girl who falls for this kind of crap: she doesn't fall for this with every guy, right? If you tried this on her, you'd fail, agreed?

Narcissism doesn't exist in a vacuum, no personality does, it is always a dialogue, a dialectic, with other personalities. God included. He pursues her not because he loves her, but because it worked. Not worked meaning she liked him; worked meaning she allowed herself to be a part of his movie.

And now she can't get out, she's always operating under the premise that it's his movie. As evidence for this, consider that Spencer had no insight about the importance of the meeting to her, in his mind him talking to her is way more important, it can't wait-- and she agreed. She eventually gets fired-- actually left in Vegas by her bosses-- but it doesn't even register. She's completely bought into Spencer's urgency, timetable, needs.

That's what makes narcissism dangerous to other people. The force of personality preys, or warps, weaker personalities-- I don't mean weak in an absolute sense, I mean weak in comparison to the steroid fueled bodybuilder who spends every moment on his identity and nothing else at all-- the narcissist wears these other people down, whether through outright seduction or relentless, manipulative, soft sells ("oh, so you only like people your friends approve of?" or "I know the real you...")

Every girl in the world has been down this road. Every guy in the world has at least attempted to pull this off.

Stop. Just stop. It's that simple, start looking at other people as people with their own movies and backstories and don't try to bring them into yours. It is destructive, you will never be happy, you will never be at peace, you'll always be thinking about how she might one day get tricked by some bad guy (read: awaken from her trance) or get caught up in material things, external things, that aren't as important as love, as commitment (read: succeed on her own, discover she doesn't need you.) And if you're a woman you'll always be wondering how you'll survive if he leaves you.

None of this is real. At best, it is a huge waste of years of your life. If you manage to break out of this cycle then one day, when you try to look back on it, it will all be hard to remember, like lost time, or it will seem unreal-- not like you're remembering your life, but like you're remembering a movie you saw, or a movie you were in. Bits and pieces, maybe some scenes, but that wasn't really me, that was a character I played...

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===== ====== ===== The Last Psychiatrist: Here's What Governor Spitzer Should Do With The Pedophiles: Send Them To Cuba

So Spitzer, et al have passed a law that allows courts to involuntarily commit sex offenders to psychiatric hospitals until they are "no longer" dangerous-- even if they have not actually committed a crime, or have served their sentence.
Said Spitzer:
"...protecting the public from those individuals whose mental abnormalities cause them to make sexual attacks on others."
"Mental abnormalities?" That they are bad people I can see; but what, precisely, is the nature of this mental abnormality? And it "causes" violence? Causes?
The ACLU of course opposes such an obvious violation of civil liberties-- but they make the same mistake:
"...locking someone up indefinitely because he has a mental abnormality and may commit a crime in the future creates a constitutional nightmare," said Bob Perry of the New York Civil Liberties Union.
"...because he has a mental abnormality." Why the qualification? Is that relevant? And why does everyone agree that there is a "mental abnormality?"
Blame Kansas v. Hendricks, the 1997 decision in which it was decided that dangerousness + a "mental abnormality" is sufficient to involuntarily commit someone (in that case, a violent pedophile) indefinitely-- even after he has already served his sentence. Here's the trick: there would be no other justification for this violation of substantive due process except some mental abnormality that forces you to do things. The only way we can justify indefinitely locking up pedophiles is to call them psychiatric patients.
What's a "mental abnormality," exactly? The Court left the definition up to the states, but it suggests some dangerous synonyms, like "personality disorder."
Here's another: mental retardation. Is mental retardation-- now a exclusion for execution-- sufficient for indefinite civil commitment? They're not going to get better, are they?
There are two main problems with this law. The first is constitutional: you simply cannot lock up a person, indefinitely, unless they committed a crime.
Exactly what is the difference between the Guantanamo terror suspects and pedophiles incarcerated further after their sentence has been completed? Both are being held under the (likely accurate) presumption they're going to cause trouble in the future. Both are driven by an inner and virtually unalterable desperation to commit their respective offenses. Hell, you can even use the same battery of questions to screen for both ("God has given you an odd gift: a schoolbus full of docile 8 year olds. What do you do?") And both are equally explained and treated by modern medicine and psychiatry (i.e. not at all.)
At least the Guantanamo detainees are not U.S. citizens-- they are not entitled to our constitutional rights. For better or worse, American pedophiles are.
If you are against one, you're against both. They're the same.
The law's second problem is social and categorical: these laws interpret certain violent behaviors as psychiatric in nature, without any scientific or even descriptive basis. In other words, it medicalizes behavior simply because it does not know what else to do with it. It says, "only someone whacked out of their skull would be a pedophile."
And some will say, and what do you expect from a culture that so sexualizes youth? Actually, humanity has been sexualizing its youth for thousands of years; it's only in modern times that we've placed an absolute prohibition on acting on it. As I recall, teens getting married was the norm in the Renaissance; the ancient Greeks had institutionalized a form of pederasty-for-education trade.
I bring this up not to justify having sex with kids (duh), but to show that it is quite obviously not a psychiatric disorder. It is a crime that you choose to commit.
There is too much emotion around sexual predators, and it confuses the issues. For example, why do we register them? We don't register serial killers, con artists, unabombers, etc. The argument, "well, wouldn't you want to know if a sex offender was living in your neighborhood?" isn't valid: I assume everyone is a sex offender. Seriously. Especially around my kids. And wouldn't you want to know the Zodiac killer moved in?

Don't misinterpret my support of civil liberties as permissiveness; if you're really worried that a sex offender will offend again, make his criminal sentence longer, harsher. If society wants to make pedophilia a capital offense, fine. But for the love of God, don't turn sex offenders over to the psychiatrists, the two have nothing to do with each other. You may as well send them to the sociologists, they have about as much to do with them.
This is an extremely bad law, and by bad I mean bad for everyone except the bad guys. It sets up the argument that certain "behaviors" are so a part of one's identity that they cannot be altered or prevented, and therefore culpability is reduced while dangerousness is magnified. It allows the government yet another avenue to lock people up without crime. And worst of all, the penultimate decision about who should be locked up for society's benefit is made by the absolute worst group to make this decision: psychiatrists. Psychiatry becomes a tool of the state.
The last major country that ran this way was the USSR. But things are different now, I know. I know.

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===== ====== ===== The Last Psychiatrist: Here's What Happened When I Went To LAX With No ID: Nothing

This has nothing to do with psychiatry, except that it's about my jet-setiing ways, and that's what psychiatry is really all about, after all.
A while ago I read an article in Wired called "The Great No-ID Airport Challenge," and I finally mustered the courage to try it.
There are two checks at security. At the first, they simply look to see if your ticket matches your ID. If it does, they send you off into one of the several metal detector lines, where you wait to place your belongings on the belt, take off your shoes, etc.
I hid my ID in a magazine, and talked myself out of my main worry: what's the worst that could happen? I mean, I can't be the first guy in LAX to not have an ID, right? Surely, there must be some system to handle these occurrences?
So I wasn't worried about being turned away so much as being extremely delayed; my fantasy was that they'd take me to the "back room" and I'd have to "con" my way through, i.e., verbally convince them I was not a terrorist.
Well, none of that happened. What did happen paralleled the Wired story: the security lady said, "no ID?" and I said, "I lost it and--" and she cut me off. And sent me over to a closed security lane, which was promptly opened and staffed. They gave me the SSS treatment-- they x-rayed and manually went through my bag, waved the wand over me, patted me down-- and that was it. I walked to my gate.
Here's the important part, in case you missed it: by not having ID, I totally bypassed the long lines in the regular security lanes. I saved myself-- what, 30 minutes?
It then occurred to me that I could have bypassed the line going to the first security lady-- another 10 or so minutes-- by walking directly up to her and telling her I was panicked because I had lost my ID, what should I do? My money says that instead of telling me to get back in line, she would have simply sent me to the empty security lane.
For those who don't know: SSSS on your ticket means you have been "randomly" selected for additional screening.   It can appear on your printed ticket, or a screener can write if if they don't like the looks of you.

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===== ====== ===== The Last Psychiatrist: The Effects Of Too Much Porn: "He's Just Not That Into Anyone"

that would be a gross misrepresentation of the facts

Imagine you are the editor of New York Magazine. You want a story that will generate buzz but no one wants to hear how hard it is to be a parent in Manhattan-- so porn it is. How about an article about how porn is making real sex less interesting to men? Conventional wisdom at $3 an issue. Nice.

Gotta have pics. You can't show porn only because the advertisers don't like it. So how about some "photographs of men watching online pornography, taken January 25"?

Sweet. Let's get five random guys and set them in front of the Pornotron:

An observation. The top guy looks like Dexter, which is good because they are all obviously serial killers.   What's the message here? That porn leads to meth?

II.

You've read the same thesis before: too much porn leads to too much masturbation and there's no cum left for the ladies, resulting in sadness and gnashing of teeth.

The article is written by Davy Rothbart, and is a mixture of personal anecdotes, interviews, and expert commentary from a key celebrity, in this case John Mayer.

It's not like there's anything in the article to dispute, it happened to him, he's spelling it all out for you in graphic detail. Too much porn made it impossible for him to perform with women. Here he is able to bone up but unable to hose down.

Had I just given up, things might have played out the way they often did, with shades of confused disappointment and inadequacy on the part of the woman and mumbled apologies and awkward shame from me. But that night, ingenuity struck--unable to actually get off, I found myself flying a fresh route: I faked it.
That's right, he faked an orgasm during a one night stand because porn ruined it for him.

And here he quotes some guy named Perry:

"I used to race home to have sex with my wife," says Perry, a 41-year-old lawyer. "Now I leave work a half-hour early so I can get home before she does and masturbate to porn." Throughout the course of our conversation, Perry insists that he's still attracted to his wife of twelve years. Still, he says, she can't quite measure up to the porn stars he views online. "Not to be mean, but they're younger, hotter, and wilder in the sack than my wife," he says.

It is a narrative that is impossible to argue with: too much porn leads to trouble, as Perry and Davy will tell you. And they did tell you, so you're on notice.

And so we are back to first principles: what does the author want to be true?

III.

I won't argue with the hypothesis that gently annoying your penis for two hours, boringly, while you surf the tubes is going to lead to some desensitization.   You have to approach porn like a bank heist: get in, get out, you got 15 minutes and someone tripped the silent alarm. Leave nothing behind.

That's not this guy's problem.

I realize regular readers are anticipating my punch line, but that doesn't make it less true. The reason he's semi-impotent has nothing to do with how he views porn, it has to do with how he views himself, i.e. completely oblivious to reality.   Observe that this guy wrote an article, under his own name, about how he can't get an erection with women because he watches too much pornography. Take a minute. He thinks this is such a universal problem that far from feeling any shame, he should be applauded for exposing the dark secret of American men.

Run through it: does he want it to be true that he's impotent?   No. He wants to be true that the reason he has sexual problems is the porn, in the same way that I have no doubt he believes the reason he can't find a job is Sarah Palin.

It is for this reason that I can make the following prediction with 100% certainty: if he never looks at porn again, if he never masturbates again, ever-- he will still have chronic sexual dysfunction. Pornography is a scapegoat.

IV.

This isn't a judgment on Rothbart, it is an indictment of all of you who want it to be true that something is destroying your lives but that something cannot possibly be yourself.

Here's the first paragraph of the article, in full:

I met the woman at a Broadway show, but the night's best piece of acting, I'd say, came from me, back at her East Village apartment, after we'd been having sex for about 25 minutes, with Neil Young wailing the song "Comes a Time" from the laptop on her bedside table. The dried-out condom had a full-bodied choke hold on me, but I'd already stopped twice to put on a fresh one, and I knew, as I kept earnestly pumping away, that one more condom wouldn't make the necessary difference. Had I just given up, things might have played out the way they often did, with shades of confused disappointment and inadequacy on the part of the woman and mumbled apologies and awkward shame from me. But that night, ingenuity struck--unable to actually get off, I found myself flying a fresh route: I faked it.
I don't need anything other than that paragraph to tell me that his problem isn't porn.   Do you know anything, anything about the woman? Forget her life choices; what color hair does she have?   Hell, even characterize her as just a sex-object, a bimbo, tell me she's got big boobs, degrade her, anything, but put her in the movie! How would you cast her? "Well, it's not really important who plays her." Got it.

But I know too much about him, none of it important, all of it branding: Broadway show, East Village, Neil Young, two condoms in 25 minutes. You could counter that perhaps the story is just made up to illustrate his point, but that only reinforces my point: this is what he imagines to be important to a story about sex.

The article proceeds to offer examples in support of the premise that too much porn leads to an inability to connect with a real woman:

Then there's Stefan, a 43-year-old composer, who has no problem getting aroused when he has sex with his wife. "In order to come, though, I've got to resort to playing scenes in my head that I've seen while viewing porn. Something is lost there. I'm no longer with my wife; I'm inside my own head."
Just like with Perry, above, you're supposed to interpret that as he has to fantasize that he's with a hot chick, but that's not what he's doing. He's masturbating, but instead of his hand he just happens to be using a climaxing vagina attached to a woman some other guy would be happy to penetrate, which is weird because that's what he's imagining anyway.

V.

Ron says that for the past couple of years, he's had weekly "dates" with his favorite porn stars, which he looks forward to all day and even showers and shaves for, as though preparing for a live-action rendezvous. "Mondays are for Gia Jordan," he says. "Tuesdays for Sasha Grey." Wednesdays he has a reprieve--a Portuguese night class. "I always look forward to Thursdays the most--Kasey Kox," he says. "Then, on the weekends, I hang out with my girlfriend."

So, Ron is insane. I don't think there's any point in debating that. Any women who finds his obsessiveness charming and are interested in auditioning for the Wednesday slot should check the casting notice:

Are you right for the part?

But the point it makes is clear: Ron has an ideal woman image in his head, and only porn can give it to him.   Real women don't measure up. We can debate the impact on women, that it forces women into gender specific stereotypes and presents women with impossible expectations of their sexuality and availability. Or something.

But feminists and Ron are reading this the wrong way. Porn is not causing him to be disconnected from women, he is already disconnected from them, and the only person that will have him is online.    He's not retreating into porn because real women don't measure up, he's retreating into it because he doesn't measure up. He's not porn material.   He doesn't expect or want that women will naturally act like porn stars in bed, he expects that he will be able to turn them into porn stars in bed, with his massive dong packing her into a creaming pliancy. It is his failure to be able to do this that drives him back to porn.

Narcissism is about the need to self-identify and to broadcast that identity to others. Online porn doesn't help you do this because it robs you of your pants, but you can run it as defense: online porn prevents other people from finding out you aren't as good as you think you are. Everyone imagines they are good in bed, but when you hit 30, 40, 50, and you slow down, now you're no longer as good as even you once were. And so you will give up sex, actual sex, something you would have previously stabbed a harp seal to get, just so you and she don't have to realize just how mediocre you are. "No, you're wrong, I simply don't have the energy." But you can stay up till 2am spinning the Wheel of Anal?

Add to that his own self-image. When you masturbate to porn, as with all fetishes, you are able to focus on a single piece of something as a proxy for all sexuality. It is super easy to look down at, say, your own penis manipulated to its max and see it as gigantic, see it as a proxy for the stud that you imagine you could be given the right script, lighting and production. But the moment the director yells, "action!" the self-consciousness kicks in. You see your flabby gut through her eyes and imagine she can't possibly be aroused by it. You don't feel sexy, so you are not interested in sex. Do I need to point out that this is what women used to say about themselves? Dude, you're acting like a girl.

You don't need to drive more than three paragraphs down to find evidence of this. Here's what one tool said about being a tool:

"I've always thought it's really hot when women in porn movies say dirty stuff," he says. "Usually, they're just literally narrating the shit that's happening, giving the play-by-play: 'You're fucking me! Your dick's in my ass! I'm sucking your cock right now!' For whatever reason, that's what does it for me. But recently a woman I was with started saying all that stuff, and it just kind of spooked me. She seemed slightly nuts."

And

Women, noticing a decline in their partners' libidos, try to reenact the kinds of scenes that men watch on their computer screens. Men, as a result, get really freaked out. They don't want their real women and their fantasy women to inhabit the same body.

They're not freaked out, he has assessed them incorrectly. Remember Sartre's "look?" This is an anti-look. This is where, as she's looking over her shoulder at you and screaming out the expletives she's learned men like, you catch a glimpse of her eyes and see behind them, into her soul, and you see that she's pretending, this is just an act, this is fake, this sex is even less real than the stuff on the internet.

VI.

Let me be clear: it's not masturbation that we're talking about, neither is it a critique of porn in general, but specifically online porn video clips-- the way Davy and Ron and pretty much the rest of America views it. What makes it so bad, and how can we stop it?

This is the approach that fails us with social issues, "what can be done about it?" Nothing, you can't do anything about the porn, the porn is a fact of reality. You may as well uselessly ask what can be done about giraffes or misplaced modifiers. Porn is here, ubiquitous, and until the government finds a way to kill you over the internet there's nothing stopping you from blowing out your retinas. We can Thomas Aquinas this issue for another decade, and maybe it is a moral issue I have no idea, but I do know that it won't change reality. You can only change yourself, and if you can't change yourself you had no realistic possibility of changing the world anyway. Stop rationalizing.

We're looking at the porn "problem" the wrong way. Because there are vaginas in it, we think it has something to do with sex or libido or even power, but strip porn down to its functionality and you'll see it's something else. Do a rundown: it's not illegal. For the most part, it isn't even shameful, you say Brazzers and every guy in American will be happy to tell you about it. "How did you know that?" "Wikileaks." It's easy to access. It's not terribly damaging. It sucks up a lot of time that you always regret afterwards, Davy and Ron may light candles and dim the lights in preparation for their "date" with but three seconds into the ejaculation they're already planning how to kill themselves. That's right, mo, that's two hours you could have spent learning to Ricky Jay a deck of cards or dictionary attack your ex-GF's facebook account. "Hey, what'd you do last night?" "Hung out." "Me too. I'm exhausted."

And: no one climaxes unexpectedly from watching online porn. You decide you're done. The first 10 minutes are thrilling but after that you're not holding back from orgasming; in fact, you're trying to remind your penis to stay hard until you find whatever it is you think you're looking for, because you think you're going to want to suddenly come when you find it, whatever it is will be so awesome you won't be able to hold back-- but it's never so spontaneous. You have to decide the time has run out. This is why online porn is so problematic: there's no natural end in sight.

And for most, the biggest problem is the drive: you don't do it because you're horny, you do it because you're bored. With porn that available, you never get to really horny anyway in the same way Americans never get to really hungry.

You're training your penis to resist physical stimulation and key off your mind, which sounds good in theory but you see the results with poor Davy-- you're training yourself to have sex in your head. So it's not that real women aren't porn-like; even porn, after twenty minutes, isn't porn-like anymore. What you need to finish is some time afterwards to create a masturbation scenario, and with some real woman squirming underneath you playing her own movie, "give it to me, Julian!" it's hard to concentrate.

In other words, online porn isn't a drug, it isn't an addiction, it isn't a sign of deviancy or a trigger for disease: porn is junk food. It is a bag of potato chips you eat when you aren't even hungry, and once you start and the initial "mmmm!" passes you're all in, may as well finish the bag, you've ruined your diet/night already, start over clean tomorrow.

After a while potato chips just figure into your routine, there's a passing thought that perhaps you shouldn't but since there aren't any obvious and immediate consequences... And now it's part of who you are.

But no one would ever say that "other foods don't measure up", no one says that potato chips taste better than steak not because they don't but because no sane person makes those kinds of comparisons. If you did, if you played it all out in your head and now deliberately avoid eating a steak in order to get to potato chips-- then you have a problem that is deeper than steak or potato chips.

Junk food is stripped of the essentials of real food, leaving just the vulgar, the simple, the obvious of taste: sugar, salt, fat, repeat. It is the pornographization of food.   The mistake people make is that they think it is delicious, but it's really just easy, comforting, reliable, satisfying. And that's where we are now: online porn is the pornographization of porn.

VII.

When you characterize porn as an addiction it tells you that it is hard to break free, that it is a struggle, that relapse is inevitable-- all things that have nothing to do with porn. But when you characterize online porn as junk food, the solution is obvious: don't eat it.

Easier said than done, I know, but the thing I find helps most people is to understand that you can't refrain from doing something you like. You can, however, change the person you are into the kind of person who doesn't even like that stuff. Sugar Smacks still taste the same as they did under Carter, but I don't know anybody who still eats them. Do the same for soda.

In medical school a lot of the guys (who went into ortho) went to the gym and would discuss with euphoria how much canned tuna they ate. "There's 15g of protein and zero fat!" they'd whisper to each other, and they'd sooner eat salamander eyes than lick a Dorito. That was the kind of guys they were.

This may not be a reassuring solution to some, but I can promise you that it is the only solution: you have to decide you're not the kind of person who wastes time on that. Condemning it, banning it, hiding from it-- all will lead to failure. Lust isn't the trigger, boredom is, idle hands are something or other, so the sooner you get a default activity, the better. When your wife walks in on you in the midst of an overhand tug and she moans, "you are pathetic!" she's really a vowel off, apathetic is more accurate and considerably more amenable to improvement.

VIII.

Davy believes porn messed up his relationships with women. I don't expect him to understand that he gravitates to porn because of who he is.

Like any through researcher, I decided to investigate a theory. I had heard about something called the National Day of Unplugging, sponsored by the New York-based Jewish group Reboot, which encourages people to take a one-day vacation from their tech. But I chose to unplug in my own way: by refusing to visit the usual series of tawdry websites I frequent before bedtime.
If you can get past the branding, you can see that Copernicus's porn usage isn't an addiction but a routine. Routines are part of your identity, like it or not, with the unfortunate consequence that you'll reflexively defend it even if it is foolish. Here is the very next sentence:

Now, I'm certainly not trying to indict porn, or to conclude that it has no place in men's lives, whether they are alone or in company. And I'll concede that some couples still find it to be something of a turn-on. But realigning one's relationship to it might just improve one's actual relationships--especially if you're often finding yourself in the bedroom, staring into the eyes of a very confused partner.
"Just don't do it" is going to be hard for him, the porn is part of who he is, but-- and this is the part you should focus on-- if he decides to be a different person he can stop that routine, and if he stops that routine he will become a different person. But he doesn't want to change, he just wants things to change.

I went without porn for a day. Then I tried it for two. Then three. On the fourth day, I had the fortune of having sex with a woman. And nothing was faked, although I can only speak for myself.

The next 40 years of this guy's life are going to be drudgery, and for anyone else he drags with him. So if that's you, for the sake of everyone around you, stop eating junk food.

---

---

You might also like:

The Near Death Of A Salesman

Don't Settle For The Man You Want

How To Lose Weight

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: He's Not Yelling At You Because He's Angry

I.

What happened is this: the junior lawyer messed up. Two years ago, he was supposed to do X, but instead did Y, because back then that's what he thought he was supposed to do.

In retrospect, it was poor judgment, but that's the way it went down.

Two years later all hell breaks loose, as they say, and Tom gets a call at his house at 8pm from one of the partners who is having a seizure. "Do you remember blah blah blah? You did X? How could you do X? Do you realize what you've done?"

Thing is, in those intervening two years about a thousand other similar X/Y scenarios have passed through his desk, he neither remembers blah blah blah, nor even at what point in his career he stopped doing X and started doing Y. Do you remember saying "aminal" instead of "animal?" same thing.

The next day he's pulled in before a bunch of junior partners and a bunch of senior partners and his junior partner lays into him: poor judgment, disastrous results, "this was a major client of the general counsel!" consequences, retributions, "this kind of thing will follow you around for the rest of your life!" and "I can't even protect myself, let alone you!" and on and on.

And its an old and primitive reaction to this kind of thing, he withdraws, he apologizes, he admits the mistake, he is guilty and ashamed but also powerless, what can he do? He starts to fantasize about getting out of here, about AAPL going to 300, about writing the novel, about hitting the guy in the throat with the head of the other guy, but ultimately he comes back to his own embarrassment. He wonders, can I get reported to the bar for this? I didn't think so, but maybe? he slinks back to his desk, beaten.

It's true: he ruined Christmas.

II.

But let's take a closer look.

They are yelling at him because they want him to eat it, to take it, all of it, leaving no room for doubt that it wasn't all his fault. Not in reality, but psychologically. He takes all the blame, but more importantly, when he does, he accepts it. That's the move. The partner is yelling because he wants the guy to accept all the responsibility; and as he does, the partner will start to believe it himself. You're to blame means I'm not to blame.

Here's how you handle a madman in a tirade: you point to the sand-- and the line you put there. You interrupt him, stop him dead in his tracks, and say this: I absolutely messed this up, I accept it. But let me be clear about something: I wasn't being lazy or sloppy-- I did what I thought was the correct thing, it was just wrong. Ok, I accept that. But the next part is this: if this is so important, why did no one notice it for two years? My work is supposed to be monitored, right? Ultimately, the junior partner is responsible for my work, right? Did it not occur to anyone that this very important client of the general counsel's-- no one thought to ask, hey, where's blah blah blah? What happened with blah blah blah? Who was working on it? Did they do X or Y? No one checked up on this very important matter?

Look, I'll do anything necessary to fix it, whatever you need me to do I'll do it. But I'm only taking responsibility for my mistake, not for the two intervening years that this important matter was not important enough for anyone to ever ask me a question about it.

How was I able to ruin Christmas?

III.

The guy doesn't want to say this, he thinks it will make things worse, because when his Dad yelled at him, anything he said would make it worse. So he just shut down, shut up.

He's worried that if he gets fired and tries to apply for a new job, when they call the old firm the junior partner will malign him to the new bosses. Wrong. He's going to malign you anyway, but if you've accepted all responsibility, and he has convinced himself that you bear all responsibility, then he'll actually rip you worse.   Your only protection is to draw a line in the sand, my buck stops here. So when he tries to slam you to the prospective employer on the phone, he'll be consciously aware that he screwed up as well. "Tom sucks as an employee, but it turns out I suck as a manager. So, take that into consideration."

IV.

None of this applies if you're actually the boss.

When you are the superior, the boss, the father, whatever, then yelling insanely is never the right move. If your subordinate screwed up, then you screwed up. The buck is always yours no matter where it stops. "Ok, we screwed up, here's what we need to do to fix it, and to prevent it from happening again..."

V.

But there are a group of people who cultivate yelling as a strategy. It's not their nature to yell, they didn't do it before in their lives. They're not doing it despite their position in life, they're doing it because of their position in life. A position that was supposed to automatically define them, but turned out empty. "(I thought being a junior partner would mean something.)" Nope.

They are yelling to communicate something about their identity. They're sending you a message. Not how angry they are, but rather that they are very important. They yell about this not because this is a big deal, but because they are so important, so pivotal, such a huge player that there is so much on them that this is "yet another thing". No, it's true, I'm huge, I'm an attending in a major hospital for Christ's sake, if you knew how much I have to worry about-- look how I yell at the med student, the cashier, the telemarketer, I'm stressed out because I'm matter.

External validation of identity almost always means: an existence without meaning.

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===== ====== ===== The Last Psychiatrist: Hey! We Just Now Invented A Cocaine Vaccine 9 Years Ago

Ah, what science really needs is a Madison Avenue publicist.

As you may have heard (from the Jan 1, 2008 Houston Chronicle:)

The needle may be one of addiction's enduring symbols, but two Houston researchers hope injections of modified cocaine actually provide the first-ever medication for people hooked on the destructive drug.

Sorry, I mean this article from the Jan 2 AP:

(AP) Two Baylor College of Medicine researchers in Houston are working on a cocaine vaccine they hope will become the first-ever medication to treat people hooked on the drug.

Hmm. That's weird. Similar phrasing and word choices.

Certainly the internet is ablaze with discussion about the clinical and ethical repercussions. Slashdot, aka "If You Don't Use Ubuntu You Probably Voted For Bush" had more comments (713) about this article than any other that week.

While the comments were (mostly) intelligent, no one thought to ask why this story appears now.

Especially since this vaccine has been in active investigation since 1999. And, especially since there isn't one cocaine vaccine, but three completely different ones by different groups. So much for "first-ever." Why didn't those groups get news coverage? Are the Baylor guys that far ahead?

Every new source (e.g. Wired) used either the Houston Chonicle or the AP version of the story, which isn't atypical-- but what about other countries? What about the BBC, surely they must have their own reporters on the case?

No. The only articles on BBC come from 2002-2004-- years when there were no U.S. news stories about the cocaine vaccine. (There was a Scientific American story in 12/04.) Why the oceanic divide in reporting, if this is relevant to people everywhere?

Follow the trail:

1996: cocaine vaccine was developed by ImmuLogic (defunct), announced in Nature.
1999: sold to Cantab Pharmaceuticals

2001: Cantab merges into Xenova
2005: Xenova bought by Celtic Pharma (really a private equity firm, that also holds the nicotine vaccine.)

ImmuLogic and Celtic are U.S. companies; Cantab and Xenova are British.

It couldn't be that simple, could it?

A possible explanation for the similar phrasing and word choice is plagiarism, but that's unlikely; a more plausible explanation is that both articles drew from a prepared statement supplied by the lab/company.

Could company publicists have called up the relevant news outlets at various times to let them know of their "new" drug? Looks that way.

But why now?

From the Chronicle:

Kosten, who joined Baylor 18 months ago, asked the Food and Drug Administration in December to green-light a multi-institutional trial to begin in the spring.

Sorry, I meant:

(AP) Kosten asked the Food and Drug Administration in December to green-light a multi-institutional trial to begin in the spring and is awaiting a response.

I certainly can't blame the companies or Kosten for the maneuver, if that's in fact what they did. A little public pressure on the FDA may be just the thing to sway votes.

Hell, I wish it worked on the Federal Reserve.

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===== ====== ===== The Last Psychiatrist: Hipsters On Food Stamps, Part 1

who wants Haterade

In the John Waters-esque sector of northwest Baltimore -- equal parts kitschy, sketchy, artsy and weird -- Gerry Mak and Sarah Magida sauntered through a small ethnic market stocked with Japanese eggplant, mint chutney and fresh turmeric. After gathering ingredients for that evening's dinner, they walked to the cash register and awaited their moments of truth.

Those are two "hipsters", and the punchline is that they pay for their foodie porn with foodie stamps, which sounds like it should be a terrible thing, except it's in Salon.com, which means they're going to try and tell you how it's a good thing, which they don't, because they can't. It's madness.

It's very easy and satisfying to hate these two, and nothing would make me happier than to hit them square in the back with a jack-o-lantern. But I also recognize that I am being told to hate them, so I have to take a step back and find out why it is so important that I hate them. I did. I should have just reached for the pumpkin.

No one but the state and psychiatry can profit from another's misery, and they are the same thing, so let's see why Election Day doesn't matter.

I.

First, the obvious: what's wrong with hipsters on food stamps is that these are college educated people who should be able to get jobs, not live off the state.   They're not black, after all. Hell, one of the two in the article is even Asian. "What, like Russian Asian?" No, like Asian Asian. "Whaaaaaaat?"

"It's the economy, stupid!" Thanks guy from 1992, but the economy did not tell you to go to college for something you knew in advance would make you unemployable, especially when that unemployable choice cost exactly the same as the employable choice, i.e. too much. Lesson one at the academia should be the importance of separating vocation from avocation, as character actor Fred Thompson and electrical contractor Benjamin Franklin both understood. When I was six I wanted to be in Playboy. Just because it's your dream, doesn't mean you should pursue it.

So what makes them hatable is the seeming choice they have made: they could work, yes at jobs they don't like but hey, that's America; but instead they choose to feel entitled to $200/month from the rest of us salarymen.

However, secondly:

Before we blame them for their choice, we should ask why they felt they could make that choice. I'm not trying to start trouble, but let's choose something I'm familiar with, i.e. women: why would a smart high school junior, 4.0 and AP Everything, think that going to Hampshire College for English Literature was a good idea? Why would her parents allow this madness, other than the fact that they were divorcing? What did she think would happen given that she knew in advance there were no jobs for English majors? Serious answers, please, I'll offer four I had personal experience with: law school; academia; non-profits; marriage. Don't roll your eyes at me, young lady: let's say you are the daughter of a lawyer and you major in English. When you were 17 and you imagined your life at your Dad's age-- not the starving poetess fantasy you wrote about in your spiral notebook, but a glimpse of the bourgeois future you then thought you didn't want-- what kind of a house did you imagine in the "if that happens to me I'll Anne Sexton myself" scenario? A lawyer's house or an English major's house? In other words, the choice to major in English was predicated on information she received from multiple sources like schools and TV-- sources I will collectively call the Matrix-- that every generation does better than the last, that there was a safety net of sorts, a bailout at the end, that future happiness was inevitable, and so we return to economics: the general name for that safety net is credit. America was the land of the minimum monthly payment. And if this analogy isn't clear enough for you, let me reverse it: the ability of the economy to offer English as a major required a massive subsidy to make you feel like $20k/yr was the same as free. If you had to pay it up front, you'd either be an engineer or $80k richer. That subsidy is now worthless, not because the money doesn't exist but because the bailout at the end, e.g the four options I suggested were operational 1977-1999 which guaranteed the payments would be made, won't help.

Imagine a large corporate machine mobilized to get you to buy something you don't need at a tremendously inflated cost, complete with advertising, marketing, and branding that says you're not hip if you don't have one, but when you get one you discover it's of poor quality and obsolete in ten months. That's a BA.

II.

When we see a welfare mom we assume she can't find work, but when we see a hipster we become infuriated because we assume he doesn't want to work but could easily do so-- on account of the fact that he can speak well-- that he went to college. But now suddenly we're all shocked: to the economy, the English grad is just as superfluous as the disenfranchised welfare mom in the hood-- the college education is just as irrelevant as the skin color. Not irrelevant for now, not irrelevant "until the economy improves"-- irrelevant forever. The economy doesn't care about intelligence, at all, it doesn't care what you know, merely what you can produce for it. The only thing the English grad is "qualified" for in this economy is the very things s/he is already doing: coffeehouse agitator, Trader Joe's associate, Apple customer.................................................. and spouse of a capitalist.

Of course I'm not happy about this, I like smart people, but that's the new reality. There was a time where women went to college to get an MRS degree, and I am telling you that that time is today, there is nothing else of value in there. Sure, some college women go on to become doctors and CEOs, and some go on to become child pornographers and Salon writers, none of those things have anything to do with what happened in college. If you are going to college to get an education and not to meet guys, you are insane, literally insane, delusional, in reality one is never going to happen and the other is going to happen anyway, and you could have gotten both for free at a bookstore. Worked for me. The only question for the future single mom is whether it's worth $XXXXXX a year to meet guys, and the answer is of course it's not, even nightclubs let ladies in for free.

It's hard to accept that the University of Chicago grad described in the article isn't employable, that the economy doesn't need him, but it is absolutely true, but my point here is that not only is he not contributing, the economy doesn't need him to contribute. Which is good, because there's nothing he can do for it. 1. Anything requiring science is out. 2. "He can work manual labor!" I love how people assume economics doesn't apply to construction. The demand for those jobs is very high AND hipsters suck at them. At any wage, Gerry the hipster will always be outworked by Vinnie the son of a longshoreman, who will always be outworked by a Mexican illegal, i.e. the system will always be able to find someone who can do the job better AND with lower labor costs. Bonus: no need to pay Jose's insurance, everyone knows Hispanics never get sick, except fake psychiatrically. 3. Hipsters are not good at retail or sales unless detached irony is required, which it is not, which is why they're on food stamps. Here's a quick test, watch this video:

Is Baldwin's character a jerk or a savior? The genius of the story is that half of you will have completely misunderstood it, and you like mint chutney and food stamps. The secret is at the beginning, at 0:15, where it is revealed that Alec Baldwin doesn't feel any of this, the whole speech is a work. If you were in that room, some of you would understand this as a work, but feed off the energy of the message anyway, welcome the coach's cursing at you, "this guy is awesome!"; while some of ===== ====== ===== The Last Psychiatrist: Hipsters On Food Stamps, Part 2

gross margin 35%. Damn right we voted for food stamps

part 1 here

IV.

"I can't tell if you're defending hipsters or hating on them."   They're ridiculous. Feel better? They're not the problem.

It's a simple thesis and no one wants to hear it: hipsters may lack drive, but the world they live in wasn't set up by them, it was set up by their parents, i.e. the Dumbest Generation Of Narcissists In The History Of The World, the ones who magnified the importance and cost of college without having any idea of what should be its purpose, let alone its content.

If you want to tell me a 30 year old hipster should be lashed for not trying to better himself, I'll bring the whip, but the 30 year old chose his pointless major when he was 17 and you think the outcome is all his fault? A 17 year old can kill two people and still be considered too young to be criminally responsible, and anyway in that case you think the problem was video games and bullying. Of course Gerry The Hipster is made of soy and ennui, but there's plenty of blame to go around. When he was 17 the system incentivized him to destroy his life, tempted him with beer, babes, and BS-- and the promise of an upper middle class lifestyle provided he went to "a good school" (read: gave the system $100k of his post tax, pre-interest money), never mind for what.   Like a good American, he did what he was told.

The society that taught people to want a defective college degree is, unfortunately, going to be expected to support those that bought it, it's still under warranty. At the very minimum, it owes them their money back, and if they don't pay you should sue for breach of contract. "At the conclusion of this course, students will show a proficiency in...." The plaintiff rests.

"They should have studied more." Agreed. But then you shouldn't have admitted them, you shouldn't have passed them. Inflate the grade, Gresham's Law the society.

All along you've said "you need to go to college so you can get a good job" but the system was not designed to raise producers, it was designed to raise consumers. Well, here we are. Why are you surprised that they need consumer stamps? Why are you surprised they moved back in with you? "We did the best we could." No you did not, I was there, I saw it. You borrowed against their future, and they can't pay it back. And now you're yelling at them.

...A Hobbit's Tale

V.

While the idea of a Metafilter post-doc receiving food stamps AND telling me they're entitled to it makes my eyes go Sauronic, it's that rage that requires some examination. Why rage? Why not just roll my eyes and go back to drinking rum and soldering op amps? What is the social importance of my rage?

Society is nothing more than individual psychology multiplied by too many to count. If narcissism is what drives this society, then only narcissism will explain it.

So start with an interesting hypothetical: does everybody need to work anymore? I understand work from an ethical/character perspective, this is not ===== ====== ===== The Last Psychiatrist: Holy Crap, I'm On Wikipedia

Imagine my surprise when I see that a major source of incoming links was Wikipedia. It's at the bottom, under "Criticisms."
Some narc is going to email me that anyone can edit the wiki, and this link will probably soon be deleted. Hey, man, why so negative, you're harshing my buzz.

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===== ====== ===== The Last Psychiatrist: Hong Kong Suicides, Revisited

A reader asked me to help promote the Hong Kong Mental Health Support Group. My first reaction (after being flattered) was to silently muse, "well, why Hong Kong only?" What's the difference?   I realize that people from Hong Kong might like the sense of community, but I'd bet anyone from Hong Kong is already plugged into a community-- why another one for mental health issues? What's the real advantage? Understand that I am not an idiot-- I see how people would feel more comfortable, but I'm asking whether there is any real, actual, measurable benefit to a culture specific group vs. a general group.
Which got me thinking of this: in the massive push for biological bases for mental illnesses, have we ignored the very real influence of culture on mental health? And suicide?   Cultural influences so strong, that they not only overwhelm biology but even probability?

In numerous articles (e.g. here) the debate is whether a famous suicide incites others to also commit suicide (who would not have otherwise) or if it simply incites people who would have committed suicide to simply copy the method.
It occurs to me that this question is flawed, because it assumes all people-- races, genders, nationalities, ages-- are the same.
Two articles about suicide in Hong Kong. for background, 95% of the people in Hong Kong live in high rises. Coincidentally, or causally, 50% of all suicides are by jumping out/off a building. 30% are hanging.
Prior to 11/23/98, almost no one ever lit charcoal briquets in a closed room and killed thmselves by CO poisoning. On that day, however, someone did do this (supposedly imitating a Japanese movie), and the case went to the front pages of the newspapers. And then this happened:

See that spike? That's not random, man.
What is even more unusual about Hong Kong, in comparison to the U.S., is that this increase in charcoal suicides was not at the expense of another method-- in other words, more people committed suicide overall--23% more:

The increase in overall suicides in Hong Kong were only related to increases in the charcoal poisonings. In essence, it was as if a whole new subset of people were killing themselves, specifically by this method.
Who were they?
Mean age was 39 (the second study found ages 24-39; compare to 47 for jumping and 55 for hanging) and 64% were men. 90% happened at home. Only 20% used sedatives or alcohol coincidentally.
Interestingly, charcoal suicides are on the rise in Taiwan, China overall, and Japan, where they had a rash of charcoal suicide pacts.
So the questions to answer-- and I'm soliciting answers--
why does the copycat phenomenon, at least with respect to charcoal, clearly exist in east Asia, when it barely exists in the U.S./Europe? Is it cultural, and what are the relevant factors?
what kind of people are using charcoal (is it different than the jumpers?) For example, is it men creeping on middle age, who have no job, live at home, etc, shamed by their lack of success?
If the above evidence is true, and the charcoal suiciders would not have killed themselves otherwise, what is it about the charcoal or the copying that incites them to want to die?

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===== ====== ===== The Last Psychiatrist: Hop, With Russell Brand: A Life Lesson For 4 Year Olds

"Hop? I'm not watching that." Well, your kids might, so you'll want to know what narrative America is using to raise them. You may not be interested in pop culture, but pop culture is interested in ~~you~~ them.

The Easter Bunny runs a huge candy factory, staffed by little chicks, and they make easter baskets and deliver them on Easter morning. It's the family business, in operation for "four thousand years," and he wants his son, EB, to take over ("someday, son, you will be crowned king of the Easter Factory!")

But the boy, EB, played by Russell Brand, is a slacker-- running a business isn't his bag, man. So he sneaks out one night and heads to-- where else-- Hollywood.

The set up is basic enough but remember this is 2011. Kids don't set off on adventure anymore, especially those who stand to inherit the motherlode. And what's up with that? How do you make a 2011 American audience accept the existence of a corporate monarchy? How do you make transferring an enormously important institution to the oldest son okay with the 9% unemployment crowd, angry at corporate perks?
There's other trouble, too: while the bunnies have been at it for 4000 years, so have the chicks. Generation after generation, they've been working in the factory with no investment in the company, no chance for advancement.
So how do you make feudalism palatable to Americans? Answer: make the bunnies British, and it simply won't occur to the audience that there is anything odd about the arrangement. So the Easter Bunny is British. Never mind he's a German creation brought to us by the Amish.
They put Santa Claus at the North Pole. Where should they put the Easter Bunny's headquarters? Remember-- he's British. No guess? Easter Island. They access the massive underground candy factories by entering a secret door in the base of the statues.

Now, you can be forgiven for thinking it's just a clever/lazy use of the name, but they didn't put Christmas on Christmas Island and make Santa's tagline, "Crickey!" So is there anything else we should know about Easter Island?
Well, the folklore of the land has it that there were originally two groups of people on Easter Island: dark skinned Polynesians, called Short Ears; and early white settlers/enslavers called Long Ears. You can take it from there.

II.

Over in America a parallel story is unfolding, but instead of feudalism it's more late stage capitalism. Successful Dad has a successful adult daughter, and the rule in movies is if you want to depict a woman as successful, you make her super hot but put her in glasses or a suit jacket. "I just got a promotion!" she announces at the dinner table as the buttons on her blouse strain to contain her success. But Dad also has a slacker son, Fred, who's 30 and has no valuable skills. But unlike EB, Fred has no legacy to inherit, and he doesn't want to leave home.

Wait a second, who's that other kid sitting there next to the daughter?

There's an extra daughter there. She's Chinese (=successful), I put her at 8. Why is she there? If the son is 30, figure that they adopted her around his college graduation. Hmmm. You almost think they adopted her because Fred was such a disappointment, and you think this partly because the only thing she says at the dinner table is, "sometimes I think you adopted me because Fred was such a disappointment." Hush, child, "that is a very hurtful statement!" To Fred. Crickey. It's a scene that would cringe you into tetanus if you weren't distracted by the blonde with the successes. Phew, scene saved.

Personal note: it's a kids' movie, so they have to sterilize everything. So we have a table with four adults eating a sumptuous meal, drinking from goblets, but not one person is drinking alcohol. Are there families in America that simply don't drink? I don't trust anyone not on probation who doesn't have wine at their table; and, while we're at it, I don't trust any man who drinks milk. Keep your hands where I can see them and no, I am not letting my kids come over.

So while creepy Dad drinks iced tea with lemon, he gives some advice to Fred. Guess what the advice is: settle. "Forget about 'great', just settle for a job that's good." Where have I heard that before?

Mom agrees: "settling is fine," she says wistfully. And she looks away dreamily. This may seem like a throwaway line except that delivered by an attractive middle aged woman it's drowning in innuendo. America isn't the land of hopes and dreams, it's the land of no prospects and settling. Remember this, we'll come back to it.

III.

We have to think about the dichotomy between the two families. The Easter business is serious business. It's a family business, sure, but a huge one, employing innumerable chicks. But "someday, son, you will be crowned king of the Easter Factory" is the kind of thing Huffington Post puts as a headline to make you hate white people.

Any chance we might inadvertently identify with the chicks?   They're basically indentured servants. Minimum wage, no benefits. Don't Americans resent dynasties, nepotism? One chick-- the foreman of the factory-- wants to be the next Easter Bunny and retool the factory to make some chick-friendly treats. He tries to impress the boss with his skills, his ability to run the business. He works very hard, he even hops and wears bunny ears to show how serious he is.

Meanwhile, EB, the true heir, couldn't care less about the business, he squanders his advantages and turns up the music. So the chick gets resentful of EB and you can't blame him: "enjoy your life of privilege," he mutters under his breath.
So even though post-Crash Americans might naturally identify with the chicks over the rabbits, in the movie the rabbits have to be the good guys and the chicks are the bad guys. So what do the chicks have to do to earn our hatred?
I wish I was making this up: they're Marxists. The main conflict comes when the chick leads a worker's revolt against the Easter Bunny and take over the means of production, so right away you have the worst kind of bad guys. Now make that hatred visceral, make that chick different from us, make it natural to hate him. Making him a black chick would have been way too obvious and racist, so they went with the next best thing: they made him Hispanic.

That's right, the bad guy in this movie is Carlos, complete with Hank Azaria's Dr. Nick Riviera Mexican accent, the face of organized labor. That's what we call a bad guy.
IV.

Let's turn to page 60 in the script like any good studio exec would. What's the pivot, the script's sell?

Fred and EB have interrupted Fred's Chinese sister's school play. She's Peter Cottontail, and sings, terribly, the bunny song. That would be a cheap Chinese copy of the original. It irritates EB, who stops the show and starts a duet with Fred that culminates in a full audience sing along of "I Want Candy." It's great, it's American, and everyone's thrilled. Well, maybe the little girl would be sad that she was interrupted and upstaged? They don't show that. My mistake-- they feature it.

I can accept a talking bunny, but I can't envision a scenario in which a grown man interrupts a school play, hurting the feelings of a little girl, that does not result in his being stabbed in the neck. But everyone in this movie thinks it's great.

She may be dressed like a bunny but she's a chick, a stand in. Remember, she's not the star of the family, is she? She was just there to keep the family afloat until he got his act together, and now that Fred's stock is on the rise we don't much need for her services. She is, after all, Chinese. And cut.

V.

EB gets his big chance to play drums on David Hasselhoff's TV variety show. He's in his dressing room, and a production assistant opens the door to tell him he's on next. The production assistant is (human) Russell Brand. EB says under his breath, "hello, who's this gorgeous devil?" Get it? Yes, we get it. But take it at face value: why would EB find a human male gorgeous?

Remember, EB's arc requires him to escape his legacy and do what he wants (drumming); and Fred's arc requires him to find a career in a land where there aren't any. So, in the final resolution of the movie, Fred decides he wants to be the Easter Bunny. That's what he's going to do with the rest of his life. NB this is a hereditary monarchy and he's not a bunny. Also NB the actual Easter Bunny and his son are still alive. So?

So EB and Fred form a partnership, hmm, an odd sort of partnership, officiated by his father who says this:

"Place your fingers on the Wand of Destiny. By the power vested in me, I pronounce EB and Fred O'Hare... co-Easter Bunnies!" And everyone cheers.

Where have you ever heard the words, "by the power vested in me?" That's right, it's a domestic partnership, a marriage of sorts, and rather than try and un-pc figure out which one's the girl and which one's the boy simply observe that person B finds actualization by completely subsuming his own identity into the business of person A, who in turn gets the leisure time to pursue other interests (like drumming.) That, my fellow 4 year olds, is an American fairy tale.

(reposted/edited from partialobjects)

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===== ====== ===== The Last Psychiatrist: Hospitals Accused of Patient Dumping To Pay
A ha ha! No, silly, the patients don't get paid.

I.

Two California hospitals are fined $1.6 million for dumping indigent psychiatric patients.

City officials allege that over two years, as many as 150 patients from the two hospitals were dumped on Skid Row, an area on the east side of downtown where thousands of homeless people live.
"We will not stand idly by while society's most vulnerable are dumped in the gutters of Skid Row," Delgadillo said in a statement.
Actually, that's exactly what you're going to do.

For the uninitiated: indigent patients frequently come to psychiatric hospitals with quasi-legitimate complaints, looking for somewhere to stay. There's no insurance, so the hospital eats the cost.
$1.6M for 150 patients is $10666 per patient. Medicaid pays, what, $700 per day? That's 15 days.
These patients are likely to have used far more than 15 days each over two years, right? Not to mention any consults (medicine, surgery, etc) for other ailments, labs, meds. And potential liability issues, potential violence... in other words, they would have cost the hospital way more than $1.6M.
So dump the indigent patients and pay the government their look-the-other-way money, you make it all back in two weeks. Faster if you get a private insurance patient in that bed. Solid.
Sounds like the government and College Hospitals have reached a mutually beneficial agreement.

II.

College Hospitals attorney Glenn Solomon denied any wrongdoing by the hospitals.

Well, there's the rub.   It's not like these hospitals threw a black hood over their heads and Guantanamoed them to a waterboarding park. I wasn't there, but I'm guessing it went something like this: "sorry, we can't admit you. We can get you transportation to a homeless shelter, if you want. Hang out here, the van will come get you in about, oh, two and a half hours. Want some juice and crackers?"

To the layman, it seems like hospitals are incentivized not to admit indigent patients; while that is only partly true in medicine, it is rarely true in psychiatry, especially psychiatric floors in multispecialty hospitals where they are accepted to be loss leaders. It is extremely rare that people who need admission get turned away; far more common is that people who don't need admission get admitted anyway; for their convenience, for the doctor's convenience, to avoid litigation or violence, etc.

If the city really thought the hospitals did something wrong, if they really wanted things to change, they would probably have come up with something more powerful than this:

College Hospitals will be required to develop protocols for discharging psychiatric patients to "ensure homeless psychiatric patients will have the dignity and the continuum of care that everyone leaving a hospital deserves."
Now that's Change We Can Rely On.

What it comes down to is that no one knows what to do with these people, and no one wants the responsibility-- but they don't want to lose all of the access (because there's money there.) Hence a passive-aggressive shifting of responsibility, back and forth. If the city really pushed the hospitals, the hospitals would push back-- "hey, you want us to handle it, reimburse us better." Meanwhile, hospitals don't want to offload all of the responsibility because they need what little revenue is derived from indigent patients.

It's like a married couple, both have secretly cheated, both suspect the other knows, so neither ever brings it up. And so it hangs like a fart over the relationship, toxic. But the only way the relationship can survive is by never having a frank discussion about what to do.

If the hospital pretends to accept that the fine has any legitimacy-- i.e. they are partly responsible for the homeless people even when they are not in medical crisis, then they can get away with a small fine. The city, meanwhile, gets to pretend that the homeless problem is a psychiatric problem-- and appear active on the homeless issue by asking for the hpspitals to change.

What's the outcome? Don't ask what benefits the homeless. Ask what benefits the city and the hospitals: a new billing code and reimbursement for the additional service of "coordinated post-hospital care." And the return of state hospitals.

Before you judge these outcomes either way, go back and find out what happened the last time we did that.

---

http://twitter.com/thelastpsych

the fun starts on fake Easter Sunday

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===== ====== ===== The Last Psychiatrist: Hot Sports Reporter Ines Sainz Was Sexually Harassed

according to my script, I'm supposed to be crying

NEW YORK (KABC) -- The New York Jets are playing defense off the field, after allegations that players and coaches sexually harassed a female reporter.

Ines Sainz, reporter from Mexican TV, somehow slipped across the border undetected to steal our jobs, only to have players throwing the ball towards her so they could bump up against her, and when she went to the locker room to interview the QB, they started "making remarks."

Complicating the matter is that the reporter in question looked like this:

Two camps:

another example of men acting disgustingly, and protected by the NFL; women being degraded and disrespected, being treated as objects.
Look at her, she asked for it! Dressed like that, what did she expect. Listen, ladies, you can't flaunt it and then get angry when someone notices.
Yes, if only either of these two had anything to do with the real issue. Come on, people, first principles: What do the writers want to be true?

II.

While it's not a justification, it is a perfectly legitimate query: how can you dress like that and not expect the attention?

Attention is one thing, lewd comments maybe another, but as Marc Maron pointed out, sexiness isn't a smart bomb, you can't select your targets, you put it out there and there's going to be some collateral damage.

"I don't want to be thought of only as a sex object." You don't see the irony of your thinking. You want people to have a certain thought, yet you also demand that they don't only have a certain thought. You're trying to control their minds just as much as you claim they're labeling you.

You don't get to make that decision, ever. As much as anyone wishes they could make everyone else accept the identity they've invented for themselves, the ugly existential truth is everyone has their own mind and they seem to have decided that you are a sex object. They may be wrong, they may be right, you can certainly try and alter this perception, but you cannot tell other people not to have it.

"You can't label me!" Throw the cognitive kill switch, after which I'm supposed to be left shuddering, did I label her? All I meant was, hey you got me all wrong, wait a second, that's not what I meant (is it?)...

Well, I ain't going out like that. I'll accept that I'm a big jerk for thinking what I think, I'll accept that I may even be wrong, but I will not accept that my limited experience as a human and the information you are giving me has lead me to a few conclusions about you that I am not allowed to have.

"I know who I am." No you don't, that's my point, if you knew who you were you wouldn't be playing multiple characters, in this case eye candy and serious reporter.   "Well, I have to act this way for the job, for TV." They didn't spring this on you last minute. It may be wrong to expect a reporter to be sexy on TV, but if you say you have to be sexy as part of the job, you can't double back and say you weren't being sexy.

What you want is to be able to behave sexy, or rude, or ridiculous, or offensive-- and still demand to be seen the way you want to be seen.

It may be unfair, but it is the most important fact of human existence: people exist independently of you.

III.

Before all the men form a celebratory circle jerk, let me back up: it's 2010. 'Well, what did she expect?' doesn't fly in Human Resources's America. Like it or not, that's reality, and you don't get to change reality. She's not a ninja, and if she feels harassed she's going to fight back using whatever she's got, and if what's she's got are lawyers, well, what did you expect?

"We don't want her to fight back, we just want her to take it." Got it. See II.

IV.

Note the power set up. All you fools think that female reporters are in the locker rooms because it is some sort of measure of equality, "why should the males get the best interviews?" that this is somehow a success for equality, something that women had to struggle to earn, and you think that because you were told that.

Women didn't earn this over the resistance of an old boy network; the media conglomerates decided it would be awesome to televise a hyperfemale in a locker room with a nearly naked hypermale and pretend there's no sexuality implied. So anything that goes wrong is between individuals, nothing to do with the Machine.

CFNM, right there on ESPN.

V.

Take a look at another sideline picture of her:

I can't believe I am the only one to notice this: she has a big ass, and 70% of the Jets are black. Hi.

"What's that got to do with it?" That has everything to do with it. Sandy Flatbutt and Ines Sainz both want an interview. Who does Marquice Cole choose to talk to longer? Which interview is going to have more sexual tension to display TV, so that everyone in America can think, "look at this guy, he hasn't heard a word she said, all he wants to do is---"

no, seriously, it's not real leather

That's how "professional news" is run. Bring the sexual energy as high as you can and then pretend it isn't there. Quoting Marshall McLuhan, "make sure the message has a nice ass."

VI.

But now we're in the middle of it.

Whatever else you may think about Sainz, this is a woman who can handle herself, and men, and players. That's the problem.

I want to say that I'm not the one who made the charge (of harassment), because I didn't even feel bad about that... the ones who say that there was something wrong was the rest of the media.
Uh oh. So nothing I wrote in this post applies to Ines Sainz; in fact, none of the controversy you are hearing applies to her, because she didn't care that much. If she can handle players, if she can dismiss this as boys will be boys, what are the other reporters supposed to do?
===== ====== ===== The Last Psychiatrist: How Am I Going To Get Paid If It Isn't Autism?

But many children whose symptoms significantly differ from classic autism--who belong only on the milder end of the autism spectrum, if they belong anywhere on the spectrum at all--are inaccurately ending up with serious autism diagnoses.

Wait: it isn't what you think.

In The Atlantic, Behind The Autism Statistics:

So parents whose kids' challenges are less severe are often urged to accept a full-fledged autism diagnosis, as otherwise they would lose access to state-funded treatment, and might, down the line, end up ineligible for support services in public school.   The result is that the autism statistics grow and grow.

In diagnoses without obvious physical pathology (i.e. anything in the DSM), doctors often give a diagnosis to a person with the express purpose of getting them benefits, e.g. Medicaid, school supports, etc.

The Atlantic hints at one side effect of this: the national statistics for psychiatric diagnoses may be inflated. I'll editorialize: not maybe, but absolutely are; we can't get paid un;ess we bill a diagnosis. In the chart we may write, "rule out MDD" and in the note indicate they were normal, but epidemiological studies don't read notes; they take billing diagnoses or look at the listed Axes.

This is compounded by "awareness"-- as more people hear about a diagnosis is, and they come in for an eval, their very presence contributes its prevalence even if they are told they don't have it.

II.

The Atlantic spends the bulk of the space lamenting the inappropriateness of the diagnosis:

[Dr.] Greenspan told me on the phone, (and later on camera), "Basically we have to misdiagnose these kids to get them help." It's the wrong help sometimes, but it's the only way to get state funding.
The concern isn't the state funding, but the odd way the government, e.g. Medicaid, covers treatments. There are "approved treatments" for autism; any other treatments are out of pocket. However, if you're not sure of the epidemiology, then you're not sure of anything else like treatment or sequelae. If the autism stats are skewed by the presence of kids with something else other than autism, then how can anyone say with any usefulness that "studies have shown that treatment X is effective"? How can any government tell you what the best practices" are?

The article talks about Sensory Processing Disorder-- if the kid has it, he has to get an autism diagnosis to be eligible for services, except

...while [the child] was making some progress, the therapy didn't seem to be addressing his biggest problems, which involved motor challenges and sensory issues, rather than the kinds of social impairments typical of autism.
I know very little about this diagnosis or its treatment. However, it's logical and obvious that its inclusion in autism will make a) autism treatment seem less effective; b) SPD treatments untestable.

III.

The article, and the supporters of "autistic-like" disorders, take (IMHO) the wrong tack: they want "Sensory Processing Disorder" to be included in the DSM, "which would turn it into an official diagnosis that would come with much-needed help."

That's the wrong approach, because it legitimizes the government's use of the DSM, and so every new treatment will have to wait for their blessing.   The better approach would be to provide coverage for treatments based on the recommendation of a treatment team, within the limit of a budget. Instead of saying, "we'll cover this treatment at $120 a session but not this other", simply provide $120/session for any kind of treatment suggested by the team.

IV.

Here's the most important secret about Medicaid and Medicare: it isn't about improving health, it is about paying people off.

While the kid described above can only get the "approved" treatments for autism, he can get the approved treatments for every other condition as well: surgery, eye evals, antibiotics for infections. In other words, his "autism" got him full health insurance.

Medicaid requires a "disability" and a very low income. The income of the child's parents is irrelevant. All kids with a "disability" (e.g. ADHD, depression, etc) are eligible for Medicaid and its services. A child can get physical therapy, occupational therapy, speech therapy, not to mention a prescription plan, doctor visits, etc -- all for free; never mind that the "child" goes to Eaton. Certainly the parents' private insurance might cover these things but it might not. Maybe the Dad owns a restaurant and doesn't want to pay for insurance.

If you have a 25 year old unemployed actor for a son who lives rent-free in your house and spends your money on chest waxing and self-tanning cream, and he can get a doctor to believe this depresses him, he can get Medicaid.

Because a disability has to be verified by a doctor and updated over time, the patient's only way of maintaining the coverage is to use it. This happens all the time. Patients will come once a month for visits, fill the Zyprexa prescription and then throw them out-- all to maintain their benefits.

Before you get angry, understand that this isn't a loophole, it is the point of Medicaid. For a myriad of reasons we do not have universal (not single payer, but universal) coverage, which would have the (seemingly) paradoxical result of reducing healthcare costs. But, surprisingly, we have a lot of poor people in the country. The government has found a way to transfer to them just enough money and services to keep them from rioting, without calling it a transfer, without calling it socialism. Simultaneously, it manages to pay doctors, hospitals, employers (through tax breaks), etc. Where is all the money coming from?

Debt.

-------------

A Boy With SPD?

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===== ====== ===== The Last Psychiatrist: How Dangerous Is Academic Psychiatry? Ask David Foster Wallace
No, not negligence, but nowhere near informed consent, either.

I've never read anything by David Foster Wallace, but I know he's got an intense readership. I also know he ultimately killed himself after 30+ years (started when he was 16) of depression. He had been on and off meds, many didn't work, and Nardil had managed to stabilize him for a while.

Then, this:

The New Yorker:

There were other important reasons to get off Nardil. The drug could create problems with his blood pressure, an increasing worry as he moved into middle age. In the spring of 2007, when he went to the Persian restaurant and left with severe stomach pains, the doctor who told him that Nardil might have interacted badly with his meal added that there were better options now--Nardil was "a dirty drug."
This passage-- especially the last two words-- stayed with me for a while. I actually had a dream about it. "Dirty drug." I could hear the "psychopharmacologist" (that's apparently what the doc called himself) saying it.

To me those two words symbolize everything that is wrong with psychiatry today.

I.

To a psychiatrist, "dirty" means the drug binds to what what makes it efficacious (e.g. serotonin receptors) but also a lot of other places that cause different side effects. For example, Pamelor is a dirty drug because it binds to histamine (sleepiness) and alpha1 (orthostasis/lightheadedness), M1 (dry mouth, constipation), etc. Prozac is an SSRI-- a selective serotonin reuptake inhibitor-- it does the one thing (serotonin) and nothing else.

No one says Prozac is more efficacious than a dirty drug, we say it has less side effects (sedation, constipation, etc.)

The problem is that there is no reason to make the distinction between effect and side effect. I get that constipation and sleepiness are "bad," but how do you know the receptors H1, M1, and alpha1 are also working in some other way to generate efficacy? Or that you don't need all of the receptors together with serotonin?

The fact that we target serotonin for depression is a fact of marketing, not of science; thirty years ago we could have gone with dopamine reuptake inhibitors and bred a generation of Wellbutrin clones. I'm not saying serotonin isn't relevant in some way; I'm saying when Abilify treats depression, don't assume it was serotonin. Or the dopamine. You simply don't know.

II.

My own observation: the words "dirty drug" are never preceded by the words "this is going to work awesomely because it's a."

As far as biases go, one could speculate that the more receptors it binds to, the better chance it has to work. Right? Why not? But we have artificially chosen to believe the opposite.

The only time a psychiatrist would say "dirty drug" is when they're about to stop it.

Nardil caused a bad side effect for Wallace, and I can't fault the doctors for attempting a change. But why say the words "dirty drug" to the family?

He's saying it because he's a cowboy, an idiot, he's using the psych lingo to show he knows a lot about the drug-- "there are a hundred things wrong with the drug, no time to explain now, trust me, I know what I'm talking about."

The family is hanging on your every word, but because of the high emotionality they don't detect nuance. They don't know what you really mean, and they don't ask because they think it's self-explanatory.

But psychiatrists love to use the lingo with patients, and no I have no idea why: dirty drug, augment, mood stabilizer. Every time you use a psych term, even if it seems obvious, you are telling them something different than you think you are telling them.

III.

The article doesn't make clear who had heard the words "dirty drug" spoken. Perhaps it is his wife, Karen Green; or it may have been his sister, Amy, who in another article seems to have finished the thought:

"So at that point," says his sister Amy, with an edge in her voice, it was determined, 'Oh, well, gosh, we've made so much pharmaceutical progress in the last two decades that I'm sure we can find something that can knock out that pesky depression without all these side effects.' They had no idea that it was the only thing that was keeping him alive." (emphasis mine, sarcasm hers.)

The doc said, "dirty drug." Amy heard: "what kind of nut put David on such a dangerous drug? Hello, it's 2008, we have way better drugs than that! Thank God you came to us. Nardil? Are you f-ing kidding me? What 1860s phrenologist came up with that? Did he try exorcism, too?"

Do you think Amy had any confidence to try and suggest that the Nardil be continued?

Note the importance to Amy of this exchange. They were nervous about changing, and I'm sure the doctor gave his reasons why he thought a change would be beneficial. But he then said "dirty drug" which conveyed incredulity and contempt. That's not me speculating, that's Amy saying it.   That, my friends, is real undue influence.   This happens all the time. If they had any reservations about changing the Nardil, that obliterated them. As a family member, there is nothing you can say in defense of a drug that a doctor has casually dismissed as dirty.

No doubt, it reinforced her guilt that she hadn't been doing the right thing for him; it reminded her of her stupidity, how could she not know Nardil was dirty?

I'm not saying I wouldn't have changed the Nardil (or that I would have). But the family never had the chance to decide if Nardil was worth the risk, or not, because the doctor made it very obvious that it wasn't.

NB: he was wrong.

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===== ====== ===== The Last Psychiatrist: How Doctors Don't Think

Jerome Groopman's book, How Doctors Think, is porn for doctors. While ostensibly about the ways in which doctors make errors, the real message is sure to elicit hands-free climax in clinicians: "good" doctors make fewer mistakes because they go beyond statistical probabilities and treatment algorithms to consider the whole patient. They use their clinical judgment. Many of the enemies are the usual suspects, insurance companies, Pharma.
While the book is worth reading, it isn't worth reviewing, I'm afraid-- I'll egocentrically say I think I already covered much of his ground.
But what is worth reviewing is a review of his book, by Charles Lambdin, a grad student in psychology. The review is called How Doctors Think They Think. And it is outstanding.

You should read the article in its entirety, this guy gets it, I'll add only two short points specific to psychiatry.
Groopman acknowledges that medicine has considerable data and science available to it, but doesn't like blindly following "evidence based medicine" because it fails to take into account the nuances of the individual sitting in front of you. Through a good interview, a doctor has access to extra information, often subtle, that an algorithm or "evidence based medicine" doesn't have, that can increase his accuracy rate. Fair enough.
Lambdin, however, points out that doctors are susceptible to all sorts of errors and biases in the application and detection of this "extra" information, that can make these augmented decisions even worse than simply applying the algorithm blindly. Touche.
The problem in psychiatry is a little different, however: here, psychiatrists make biased and error-prone judgments-- often simply prejudices-- that they use to augment studies and evidence which themselves are faulty and biased. It never ceases to amaze me how people are suspicious of drug company studies, but not at all suspicious of studies from the universities or the NIH-- they don't have any biases there? Is it magic that allows me to predict that an NIH study will find the generic the best choice?   Researchers not only can influence the data-- mostly unconsciously, but also by not publishing a study that didn't show the expected results-- but also which questions to investigate, and how questions are framed. Is there any possible reason Harvard, Yale, and Cleveland will always find a reason to study Depakote or Lamictal? And now Seroquel?   But not Zoloft (now generic?)
An example of this is the the doctor who has a patient who has no history of bipolar, and any rating scale or screen would not suggest bipolar, but uses his clinical skills (read: bias) and says "there's something about him" and "discovers" that the patient is an undetected bipolar-- but then puts him on Depakote, because that's what the "evidence" shows is the first line for bipolars. Really?   Which studies did you read, again? The orange ones? In the Trapper Keeper?
As anyone who has ever dated a girl who was too much into the occult will tell you, astrology is difficult. It has a highly structured set of rules-- math, really-- so precise and complex that, theoretically, any two astrologers should independently arrive at the same result, which is correct enough times to keep people from breaking out into hysterical laughter all the time. However, astrology is crap, right? Some other factors explain the few successes. Is the fact that so many schizophrenics are born in the spring related to Mars rising in Orion, or to a virus women contract in the winter? Etc. In other words, just because a system is reliable, doesn't mean it's valid.
The other point is on the subject of "zebras"-- rare, outlier diagnoses that should be investigated last after more common and likely ones. Lambdin writes:
Oddly, Groopman rebukes doctors guilty of “zebra retreat,” but bungles the example this term is derived from. He quotes: “When you hear hoofbeats, think about horses, not zebras.” The actual lesson is, “When in Wyoming, if you hear hoofbeats and think you see stripes, it’s still probably a horse.”
In psychiatry, however, the problem isn't suspecting a rare disorder before a common one; it is inventing a disorder rather than dealing with the complexities of a person's life. "It's not bipolar--he hasn't responded to Depakote or lithium-- I think it may be Intermittent Explosive Disorder." If you apply the same rigor, analysis and logic, alien abduction is also on the differential. As I've written before,
the real problem of a critique of our cultural models is to ask, when we see a unicorn, if by any chance it is not a rhinoceros.
-- Umberto Eco
(Thanks to reader Walter F for sending me Lambdin's review.)

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===== ====== ===== The Last Psychiatrist: How Does The Shutdown Relate To Me?

is Obama there?

Everyone knows ads are propaganda, but what happens when you have an ad for propaganda? While you sip your first Guinness and try to figure out why China's government can only ever shut down once, you can ponder this ad:

The only reason you haven't spit nitrogen bubbles on your screen is I haven't shown you the other half of this outstandingly accurate abomination. You should get yourself a towel and another drink.

I.

Intelligent people like to tell each other that they aren't liberal or conservative but independent; that Fox and MSNBC are biased and can't be trusted, that partisanship, "special interests" and "lobbyists" have destroyed America; in essence, that they are not ideologues but practical, reasonable people who just want the system to do what's right. Then you ask them what exactly "right" is, and the yelling starts.

Intelligent people, like racists, are fluent in describing themselves in opposition to what they are not, but ask them to define themselves by what they are, tell you what they do believe in, and they're lost. They have opinions on issues, sure, but ask for an overarching ideology and their face botoxes. Overarching ideology? Only people with manifestos have ideologies, not having an ideology is the whole point of being independent, the only thing they deal in is "facts" or "reality", and gun to head if they believe in anything it's "science." Not physics or chemistry, but evolution. You know, whatever ideologues hate.

I phrase it this way not to insult a group, but to show you how very easy it is to brand identify a group, because when a group becomes a demo it loses most of its freedom of action and becomes baa baa black sheep. Do you want to see the consequence? Turn on CNN.

II.

"The government shut down just shows that our government doesn't function correctly!" That's one interpretation, the other is that when a car starts to smoke, you pull over and fix it, you don't keep going till it explodes, though I recognize the explosion makes for better TV. What you're seeing is the ordinary back room realigning of interests and powers, but this time trying desperately to hide from a voyeuristic media that caters to a demographic, i.e. you, that believes that never more than three at a time colorful but poorly understood #issues will eventually get us to Mars. "We shouldn't go to Mars." You got your wish. Off topic, speaking of Mars, here's an interesting thought: if things proceed as per y=mx+b, then the entire human race of the future interstellar diaspora will all be Chinese.   Huh. What do you know, Star Trek was way off.

Americans, by which I mean a populace propagandized to the Left or Right or Middle, cynically believe that "wanting to get re-elected" or arrogance or ideology is what's to blame, as if 500+ career Machiavellians are too stupid to know what an underemployed theater grad knows. "They should just do the right thing!" Who will let them? You?

The shut down was the inevitable consequence of a government not permitted to compromise, smothered by the oppressive gaze of a kamikaze media that will kill itself and your country just to get a headline today. I'm starting to wonder if the reason it is always pretty white girls who get kidnapped is that the media is the one kidnapping them. And you blamed Bear Stearns for being too focused on short term profits? CNN's time horizon is your next micturition.   The media demands partisanship, conflict, opposing sides, but despite having 24 hours to fill will never, ever explain the interplay between complex issues, preferring to feature them in segments while hyping them to a crisis.   Imagine trying to have sex always on camera, and always with a goat, and always with some know-it-all screaming at you, "get hard now! NOW! 8 seconds left! NOW! What's wrong with you?!" Jesus, can I take a minute and do this privately? "Transparency!"

If Senator X "makes a concession" the relevant media will proclaim him a loser and a coward, they don't want representatives, they want cage fighters. There's no reward for compromise and there's no safe place to attempt it, either. This is 100% your fault, "I can't believe how stupid these people are!" It's great how you can't find employment but have time to micromanage the U.S. Senate. #outrage

If you want to know what political career disaster looks like, have an infinitely leggy ex-sorority girl in flesh toned Manolos sitting behind a glass table in perfect lighting announce to 50% of America that you were beat by an old woman from California or an old man from Ohio. "Ha ha, what a cuckold! Back to you, Kent." You blame Congress?   They are the ones who "don't get it"? When a representative democracy gets crippled by what amounts to a 3x3 magic square, it's not that they can't figure out the solution, the solution is easy, the answer is 15 and the five is a gimme, we just need someone to dare allow himself to be filmed putting the 1 on the left or the right or the center so we can finish the other 13 numbers and go bomb Syria.   "Wait, what? I don't understand." Yes, that's my point exactly.

III.

I'm not saying the shutdown isn't a real problem, only that if the news came out only in weekly format, this particular shutdown wouldn't have happened. Or, said differently, if there was a government shut down at a time when the news came out only weekly, it would mean we were getting a new flag.

All of what is now being subverted by the media has been detailed in The Process Of Government, you should read it. But you won't, it has too many characters, and this is accurate no matter how you define characters. Come on, at least read Chapter XX, it's online. Jesus, here. "Umm, It's pretty boring." I know, I know, you want to know how the news relates to you, and boy oh boy do I have the news network for you.

"But that book was written in 1908. Based on what I've seen on Downton Abbey, things were a lot different then."

Well, yes, obviously, there had just been a massive leap forward in technology and industrialization, a booming economy fueling a wealth gap, temporarily course corrected by a financial panic "precipitated" by the failure of two overspeculating brokerage houses. There were also, simultaneously, great advances in progressive causes like worker's rights and food quality, all on the background of decreasing importance of religion among educated whites in favor of science. Not physics or chemistry, but evolution. Tabloids were incomprehensibly popular, partisan media the norm. A loosening of conventional morality manifested as bored promiscuity, female bisexuality, and a flood of new porn the likes of which never existed before.

"That does sound different. And awesome. What did their Millennial kids inherit, what did they experience over their adult lives, say 1929-1945?"

I totally don't know, Boardwalk Empire only goes up to 1924 and Mad Men starts 1960.

IV.

The problem with blaming the shutdown on Congressional partisans is that the partisans on either side know exactly what they want. When there are specific things you want, compromise is usually possible.

The public in the middle, however, don't understand politics, only emotions given to them by TV, and so their beliefs are cobbled together in real time, improvised, as they get "more information." One trending topic at a time, each vacuum sealed to prevent cross contamination. They don't look at things historically, culturally, humanistically, or even selfishly, there exists no system for interpreting "the facts." Compromise becomes impossible, as a simple example, when a "moderate" "thinks" there should be more restrictions on guns, they want gun owners to give up something they want very much-- in exchange for nothing. "But it's the right thing to do!" And the yelling starts, in HD.

Worse, they proudly announce their lack of ideology by branding themselves as Independents-- capital I, a thing, a demo. He willingly lessens his independence to become part of a group.

The "independent" demo actually has all the textbook characteristics of a group most susceptible to propaganda, more correctly "pre-propaganda", and by textbook I mean literally Propaganda.

They consider themselves leaderless. They can have representatives, they can have "evangelists" but they have to believe that their conclusions are all their own, through individual reflection and objective consideration. Interestingly, and on purpose, they believe their brains can handle such an analysis, any analysis. This isn't arrogance. They are told, by universities and the media, that their mind is prepared to do this heavy lifting as long as they are given just the right facts, filtered from the "noise." "Where can we get the right facts, in a world of liars?" Good question, maybe the news?

Commonly, independents have a single personal issue, say gun rights or abortion, but no personal experience with other issues, and lacking any subjective starting point, they therefore believe that ONLY objectivity will give them the truth. The less life experience they have the better; the less they've seen of the world, the fewer people they've argued with (in person, where it is real and has real consequences like punches), the less frequently their water balloon worldview is tested by people with pins, the more they will cling to the premise that "facts" are what's important. In this way the one personal issue serves as a reference point which the propaganda exploits: "hey, gun advocates, did you know you like low corporate taxes?" I do? "Yes, because the people you hate are for raising them." Consequently, raising corporate taxes is felt like an attack on the Second Amendment. "Liberals! Taking away our rights!"

But sometimes the complexity of issues is just overwhelming, once in a while reality creeps in, and issues are discovered to be massively complicated, and anyway he has no power to do anything.

No doubt this sounds depressing, he's going to start drinking heavily, or become a cynic, or go the Hemingway. So the media=propaganda fosters his regression towards a much desired solution: total alienation. The media explains how things relate to him, and as long as he understands what's going on, he feels empowered. He is given an ideology without even knowing it. Now he doesn't actually have to do anything, indeed, it's way the hell better if he does nothing. All that's required is support, and through his support not only will "the right things" happen but he'll share in the credit.

You'll counter that there are right leaning and left leaning independents, isn't there a difference? but this misses the point: propaganda doesn't try to get you to believe something, but to do something, and in this case it is to do nothing-- it doesn't matter what you choose to believe, as long as your outrage is done from inside your house.

This is the whole gimmick of media, not polar but triangular, right, left, middle, mobilizing an army of assonauts to feel strongly enough about something that they don't do anything.

I already knew that "independent" was a group looking for representation, what I was surprised by is how fast "independent" became a mainstream brand demo. Here is page 2, and 3, of Time Magazine:

The first and most immediate observation is that Al Jazeera assumes its American target demo is stupid, very stupid, because here we have what is most certainly a college graduate who considers herself in need of unbiased, objective, independent news-- yet she is still reading Time Magazine, as her main source of in depth news. Rana Foroohar balanced by Fareed Zakaria, two wrongs can make a right, and "it's somewhere in the middle." She has decided that the problem with her understanding of the world is that she just needs better intel. Yes, she will say intel, it sounds more objective.

In order for the Time reader to have formed the quoted thought two other thoughts had to have occurred already, which in itself is astonishing, here they are: 1. She's figured out that all American news is biased, she's sick of the partisanship, after all, it doesn't brand identify her. 2. She thinks that more objectivity is to be found at Al-Jazeera America.

Why would she think this? Because she's stupid? Actually, yes: the culture you know least about has all the answers, which is also why the Guinness ad hypermale in pre-season Special Olympics has chosen to tattoo gigantic Chinese characters on his arm to explain his ennui to himself. "It's a chinese proverb, 'That what doesn't kill me make me stronger.'" I hope to God a bus tries to make you stronger. Off topic, as a sociological metric, you can track a chinese person's first level of alienation from his culture by his branding himself with English-word tattoos; but you will know that all the chinese has been media powerwashed out of him when the he starts getting Chinese character tattoos. "It's because I'm Chinese," he'd explain, to which you would not dare reply, "yeah, I kinda figured." To which he will then not reply, "I mean, I know I'm genetically Chinese, but I don't really feel Chinese, but this signals that I'm part of a symbolic China more authentic than the actual China of my parents which I feel no real connection to, yet I know I'm supposed to feel the connection, it's not like I can go around pretending I grew up on Waltzing Matilda." To which you will not add, "It's not entirely your fault, you didn't live through a war like your parents and grandparents did, and anyway modern China resembles the U.S. far more than it does symbolic China. Technically, you're alienated from your parents alienation, but neither are you connected to Americana either, the white girls/boys seem out of reach, there's a frivolity you can't really empathize with, jobs other than Law, Medicine, Science are unreal, and you feel like you're always looking at everything from an outside that itself has no firm location." And he'll blink, confused, "truth be told, my only real association to chinese culture is my parents screaming at me that I'm not as good as 'real' Chinese. What can be done?" I don't have an answer for you, the good news is that when you finally find the answer that works for you, your kids will be too old to care.

Al-Jazeera America is trying to call itself "objective", but right in the ad is the brand reveal: she doesn't want objectivity, she wants subjectivity explained to her, she wants to know how the news relates to her. She wants to know: how can I, an organ donor in Sector 3, be part of the global community now that my husband is boring and my kids prefer their individual LCD screens? The media wants her to have an answer, after all, do you know how many Nielsen ratings that family generates, how individualized is the data? It's not the quality of the news at AJA she likes, but how watching it makes her feel smart, unique. She's not going to watch Fox, MSNBC and AJA, right? Only one of those, but AJA brands her as out of the mainstream, unique, open to other opinions. "I like to get my information from different sources." I assume that includes twitter, 140 characters and an appeal to authority and you're good to go at the Starbucks.

V.

To be clear, I'm not at all worried Al Jazeera is going to secretly convert this woman into a jihadist or spread misinformation and disinformation. I have no doubt Al Jazeera will be as objective as CNN, after all they took Soledad O'Brien from them to signal that very point.

So when I say AJA is (pre-)propaganda, I don't mean it won't be accurate, I mean that it's purpose is to prepare its demo for a certain way of life. Of course everything I've said applies to any American media-- except that Al Jazeera offers something else the American networks don't or can't. If you want to know what Al Jazeera is really offering, take a look at its aspirational target demo:

Not pictured is a white guy in a suit, because he already has media that's for him, and it's probably Fox, and the above four people hate it. That's powerful branding in America: in opposition to what you hate.

Women and minorities may not seem like an aspirational demo, but it is-- not for actual women and minorities necessarily, but for people suffering from tremendous ennui who want to be part of a struggle, something bigger than themselves.

They feel, without fully comprehending this to be true, that the only reason the American media is so partisan and loud and angry and urgent is because nothing really important is happening. Yes, there's a countdown clock on CNN for Debt Ceiling Armageddon and I guess Kanye West is headed for the asylum but it's all boy who cried wolf blitzer at this point. She heard, like you heard, that the NSA is monitoring us, and you know what? Meh. Though it was interesting when it was on The Good Wife. This isn't to say things are going well, it is to say they are degrading boringly. Like the above woman's marriage.

This is what Al Jazeera promises her, not objectivity, but a connection to history. Our big crisis is... whether or we aren't going to pay our short term debts. You think either of the four people above can get hyped about that? But over in the middle east history is happening, racial equality, women's lib, the right to get an education, riots, ideological clashes-- all that stuff is happening over there. Women are being stoned to death for seeing a penis, gay men, too, if you assume that at some point in some future these things will no longer be true, then you are saying that historical changes are afoot as the old ways are replaced, and by ways I mean men.   The #OWS demo wants to see powerful men humbled before the t-shirted, tweeting masses, it allows them the fantasy that it could some day happen here, which it won't because the propaganda worked.

Propaganda doesn't succeed because it is manipulative, it works because people WANT it, NEED it, it gives their life a direction and meaning and guards against change.

Fans of AJA will probably attack me for being biased, but this accusation is silly. The whole point here is that the target demo for AJA is not smart, and I know this because no one smart would watch TV news. If you are watching TV news, then you're not smart, this isn't me saying this, this is TV news predicting this: no one smart would ever ask another person, let alone the news, to explain to them how the news relates to them. TV news thinks you're as stupid as Time Magazine.

If anything, Al-Jazeera isn't the "Islamification" of the west, it is the westernization of the middle east. Al Jazeera reports in English, they have western values, and, most importantly, accept ads-- western style ads, i.e aspirational, not representational.   The neocons couldn't have planned this better, someone should check to see if they didn't. Two months of Al Jazeera and this woman will turn to her then deceased husband in a moment of big picture clarity and say, "you know, they're not so different from us, they want the same things we want." Yes. Why do you think that is? Evolution?

The news for Americans, especially Independents, lacks meaning, direction, ideology-- and they miss it, just like economically, they've been left behind. Now the news is artificial drama, just local crime stories blown up nationally, a natural disaster, the occasional Youtube video-- where's the Change, where are the upheavals, where are the riot police? We don't have political riots here, we have high end sit ins near the Broadway Starbucks, and occasionally 20 motorcycles will attack a minivan. "Is 'motorcycle' code?" That's where we are right now, this is what the media has trained you for, detecting racism or hypocrisy or some other character flaw in the speaker as a proxy for the complexities of the issues so you don't have to think. It is under these conditions that you expect John Boehner to "compromise" on something you don't at all understand, and scream for his beheading if he doesn't, all to the thrill of the media. "See! TLP is a right wing zealot!" See, you're stupid. And boy oh boy do I have the news network for you.

===== ====== ===== The Last Psychiatrist: How Do Antipsychotics Cause Weight Gain?

In order for this post-- and any discussion on antipsychotic induced weight gain-- to make sense, you have to understand one thing: each antipsychotic seems to cause weight gain by a different mechanism, not varying degrees of the same mechanism. Because let me tell you right off the bat: researchers here are far from agreed.
A review of some articles:

In rat pancreatic beta cells, neither clozapine nor haloperidol had any effect on basal insulin release. In the presence of high glucose, haloperidol had no effect on the normal insulin surge, but clozapine inhibited this effect by 40%. How it did this is not clear, as clozapine, in the presence of glucose, completely suppressed electrical activity by hyperpolarizing the membrane potential (i.e. increased K+ conductance.) Haloperidol depolarized (inhibited K+ conductance). Thus, by completely suppressing electrical activity, it should have completely suppressed insulin release-- but it only inhibited 40%. Similarly, haloperidol should have increased insulin release (via depolarization) but it didn't have any effect. We don't know what would have happened if the study had been continued for a year; but note here that the effect on insulin is dependent on the presence or absence of glucose, not the other way around.

Most studies focus on the changes in serum parameters (triglyceride, cholesterol, insulin, etc) and not the mechanism for these changes.
For example, in 112 schizophrenics on meds for 8 weeks, Zyprexa, clozapine, Risperdal, sulpiride all increased insulin and C reactive peptide, as well as insulin resistance; but only clozapine and Zyprexa increased triglycerides and cholesterol, and had a greater impact on insulin, insulin resistance, and C-peptide. What you can't tell is when this happened and what came first: did the insulin go up as a direct effect of the med, and consequently so did cholesterol, or did insulin resistance happen first, etc?

In the first study looking at the drugs' effects on GLUT1-5 mRNA, it was found that Remeron (mirtazapine) increases GLUT4 (muscle/fat) and 5(intestine) mRNA, and Haldol and Zyprexa increase GLUT5. No effect on GLUT1-3. (Contrast with Clozaril and Risperdal, below.)

The authors propose something interesting about Remeron: "Therefore, the increasing effects of mirtazapine on GLUT4 mRNA levels in our study might lead to a decrease in blood glucose levels and to an increase in cellular fat deposition, leading to intermittent or continuous lowering of blood glucose levels with a subsequent increased uptake of carbohydrates and other types of nutrients." In other words, better glucose uptake into cells means more fat inside cells, and less glucose outside cells (hypoglycemia)-- which is a stimulus to eat more.
This is important, so I'll repeat it: the hyperglycemia seen with Zyprexa and Remeron is here proposed to be due to the acute lowering of blood glucose (because of increased transport), and thus an increase in eating and fat deposition, and consequently insulin resistance and hyperglycemia; not a direct affect on glucose metabolism.
(Consistent with Zyprexa's effect on GLUT5 (and not on carbohydrate metabolism, per se), metformin did not prevent weight gain in 40 people on 10mg Zyprexa (all gained 5-6kg in 14 weeks.)

In (male C57) mice, over a 6 month period, clozapine, chlorpromazine and quetiapine induced hyperglycemia via effects on glucose transport. Haldol and amisulpiride have little effect on GLUT, and were found not to induce hyperglycemia.    Risperdal had a medium effect on hyperglycemia, but at the lower doses.

Using rat pheochromocytoma cells, clozapine and Risperdal both inhibited glucose transport (i.e. GLUT3).
Desmethylclozapine (a metabolite) was an even more potent inhibitor, while clozapine-N-oxide, the other metabolite, had no effect on glucose transport. Clozapine and fluphenazine also inhibited glucose transport in (rat) muscle cells. The drugs block glucose transport in a non-competitive (i.e. allosteric) manner (and tricyclics appear to work in the same way.) What is interesting about this is that different people metabolize clozapine differently, and perhaps those who create more desmethylclozapine get more hyperglycemia than those who make less (and/or more clozapine-N-oxide.
A follow-up study tried to correlate the toxicity of these drugs to cells to their inhibition of glucose transport.
They found that clozapine, desmethylclozapine, Seroquel and fluphenazine were toxic to cells; Risperdal was minimally toxic; and Zyprexa actually promoted cell growth.
Seroquel, Zyprexa and clozapine all inhibited glucose transport about the same amount, and in a dose dependent manner. (Remember: Haldol and sulpiride don't.)
However, if the cells were exposed to drug for a longer time, fluphenazine greatly inhibited glucose uptake, clozapine had no effect, and Zyprexa increased glucose uptake. In other words, the toxic typicals only need a sort exposure to kill a cell, while less toxic atypicals need prolonged exposure. Also, fluphenazine increased GLUT3, and the atypicals had little or no effect (as found above.)
Zyprexa was found not to affect either the basal or the insulin stimulated glucose transport via GLUT1 or 4. (Fun fact: bovine serum albumin (or impurities therein), used to replicate the fact that olanzapine is highly (93%) protein bound, actually increased basal glucose transport, making suspicious all studies previosuly done with BSA.) This contradicts the findins of the Dwyer articles, above, where antipsychotics had inhibitory effects on glucose transport. A possible explanation could be dosing: this study used doses comparable to 20mg, while others used 20x that amount.
Another study, in humans, found that neither Zyprexa nor Risperdal affected acute (3 week) insulin sensitivity. Again, what happens after you get heavy is up for debate.

So what we have here is confusion, but:
1. acute, high dose in vitro studies indicate that typicals>atypicals inhibit glucose transport, but Haldol does not.
1b. Typicals are toxic to cells, atypicals less so, and Zyprexa promotes cell proliferation.
2. Normal dose and human studies show no effect on insulin dependent glucose transport (i.e. GLUT4) but there are effects on small intestine absorption (GLUT5) with Zyprexa and Remeron.
3. Clozapine inhibits insulin release in the presence of glucose, but Haldol doesn't.
4. Acute effects may be different than chronic. i.e. even though antipsychotics may not directly affect insluin resistance or glucose transport, if they make you hungry or increase fat over time, this could result in later insulin resistance, hyperglycemia, etc.

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===== ====== ===== The Last Psychiatrist: How Do You Lose Weight? Which Diet Is The Best?

There are a lot of studies about diets and even more studies about weight loss drugs. So why can't we decide which is the best diet?

There's a stack of studies a meter high. "Look," they say, "the evidence is pretty strong that they are all the same." Really? That seems intuitively wrong-- shouldn't some diets be better for certain people? And yet, there's the stack.

This post won't tell you which is the best diet. You can go back to Oprah.com now.

This post is about why the studies can't tell you this.

I.

Most clinical trials have high dropout rates. What do you do with them?

1. You could use only the data of people who finish the trial, so you can say, "it had a 100% cure rate for the 13 people that didn't explode."

2. You could leave the last recorded score intact, and just carry it to the end.

Clinical trials have usually employed #2: LOCF: the last observation carried forward.

Researchers regularly remind us that this type of analysis can potentially underestimate the effect of a treatment. If a patient drops out because of side effects after one day his score will remain "sick", bringing the overall average down. Perhaps had he stayed on the medicine, he may have been cured.

Example: consider N=2. One person gets cured, the other person dropped out on day 1 (no improvement.) So the study found that Drug A gets you 50% improvement. Unhelpful.

II.

Here is an unrealistic example for the purposes of illustration. Take a bunch of 300 lb individuals. I give half a 100 calorie diet, and the other half a 5000 calorie diet. Read it again. Which will result in more weight loss?

After one day, most of the 100 calorie diet group drop out-- "this sucks"-- and so their last weight carried forward is 300 lbs. Average weight loss at the end= 0 lbs. If the 5000 calorie people can stick to the donut-ham-hamburger diet and lose even a single pound, the study would conclude that the 5000 calorie diet resulted in more weight loss.

The study isn't useless, because it tells you something very important: across a population, the 100 calorie diet is going to fail-- most people like dessert.

But that doesn't tell you what to do. This study does not help with that decision at all. In fact, it may confuse you because now you are confronted with the evidence that the 5000 calorie diet is better, or at least not worse. Bacon up.

Studies can be further misapplied when they (read: media) overgeneralize the results.   Are all obese people obese by the same mechanism?

Point: in an LOCF study, dropouts don't just minimize the importance of the study, they ruin the study if all you are doing is looking at the primary outcome. Point 2: you can't take the results of an LOCF study and simply apply it to an individual in front of you. You have to consider the contex. "Most of the people who dropped out did so because of X. Is this likely for my current patient?"

III.

Now consider an FDA trial of an appetite suppressant.

Lorcaserin is a new 5HT2C agonist (think opposite of Remeron) that theoretically promotes satiety and/or suppresses appetite. What happens when you give it vs. placebo to a bunch of 100kg people who are told to exercise and eat 600 less calories a day, for a year?

You see that the placebo group lost an average 2.2 kg, which was 2% of their baseline body weight, while the lorcaserin people lost about 5.8 kg, which is 5.8% of their body weight.

Is that 3.5 kg difference meaningful? No: according to the FDA, you have to beat placebo by 5% or you don't get FDA approval. To the FDA, this failed a primary efficacy measure.

However, in theory, the drug should work in certain kinds of people-- maybe those whose obesity is a function of hunger? How many people were able to lose significant weight, like 10kg? Answer: three times more than with dieting alone.

Is this a drug you'd be willing to try? There is a group of people for whom the drug might be awesome-- if you could predict who those people were.

The study becomes difficult to interpret because 50% of the people dropped out. When did they drop out? Doesn't say.    But if 25% of them had dropped out by the fourth month (4kg or less weight loss)-- let alone earlier-- the rest of the people would have had to have lost about 7kg in order to generate an overall average of 5.8kg of loss-- and those guys would have met the required 5% superiority required by the FDA.

I'm not saying that happened (or didn't happen.) I'm saying that for the purposes of practicing medicine, you cannot say "studies show this drug works/fails" without an understanding of why it worked/failed.

IV.

Now take the Atkins diet: is it better than conventional "low fat" diets? Let's ask the gated community socialists at the New England Journal of Mendacity:

(from N Engl J Med 2003; 348:2082-2090)

You can see that at 6 months, the Atkins diet people lost more weight.

But, it's LOCF: by month 3, 30% of the conventional diet people bailed, vs. only 15% of the Atkins. If you assume that very little weight loss went on in the first three months, then the weights for the conventional diet will appear heavier than they could have been, dragged "up" by the dropouts who lost no weight because they didn't stick to it.

We won't know what could have happened if all of those conventional dieters stuck to the plan. This isn't to say Atkins didn't work; it is to say that it may not have been better.

Analyze the data a different way. Instead of using the morally weak quitter's last score to carry forward, the authors reverted to their baseline score (e.g. no weight loss), no matter how much weight they had lost in their brief time in the study.

If you take the curve using this analysis (B above) and compare to the LOCF (A below), then there are three possibilities:

If they initially lost a lot of weight, then this analysis would "artificially" worsen the curve (i.e. make it appear like there was no weight loss.) A curve would be higher than B curve.

If they had magically gained weight before dropping out, then this analysis would hide that fact and the B curve would appear lower.

If my assumption is correct-- that they didn't lose much weight in those early months, then the curves should be the same.

Note that for the conventional diet, the curves are almost the same: they didn't lose much weight, and they dropped out. The effect at month 6, therefore, is to make the overall weight loss of the conventional group appear less.

In other words, conventional diets may not be as good; or they may better. The same can be said about Atkins, which is to say, nothing can be said at all.

The point here is about the studies showing Atkins is superior: they really mean only that more people stick to it.

V.

Now to the meat of the issue. What about all the studies that show that the diets are the same? Surely those aren't flawed?

Let's find out if the percentage of fats, carbs, and protein matter for weight loss. Let's pull a major study from the stack, something from the NEJM:

800 people put on various diets: high/low protein, high/low fat, and a range of carbs, e.g.,

20% fat, 15% protein, 65% carb
20% fat, 25% protein, 55% carb
40% fat, 15% protein, 45% carb
40% fat, 25% protein, 35% carb

Check back at the midterm elections. Which was the best?

From the Discussion:

Discussion
In this population-based trial, participants were assigned to and taught about diets that emphasized different contents of carbohydrates, fat, and protein and were given reinforcement for 2 years through group and individual sessions. The principal finding is that the diets were equally successful in promoting clinically meaningful weight loss and the maintenance of weight loss over the course of 2 years. Satiety, hunger, satisfaction with the diet, and attendance at group sessions were similar for all diets.

Or, from the abstract:

All diets resulted in the same weight loss! This proves it! Oh, wait, this was published in NEJM, where peer review= spell check. Better look more closely.

Though patients were told to eat a high fat (40%) vs. low fat (20%) diet, using a fixed protein amount, here's what they actually ate:

That difference of 20% has been reduced to a difference of 7%, i.e. what should have been a difference of 33g of fat is now a difference of 11g.

What about high (25%) vs. low (15%) protein diets?

That 15% vs. 25% difference in average vs. high protein diets has been reduced to no difference whatsoever. In fact, these people all managed to eat 20% protein no matter what diet they were supposed to be on.

So this study did not test various diets against one another; it tested essentially the same diet four times. And it found that pretending to be on a high/low protein/fat diet has very little effect on the outcome, which if written that way would never made it into Children's Highlights, let alone NEJM.

Strangely, that's not the finding reported in the media-- or even by the lead author himself:

How could it matter if it wasn't actually different?

VI.

So what do these studies stacked a meter tall tell us? That lorcaserin doesn't work (except when it does work awesomely); conventional diets suck (except in those who stick to them); Atkins diets may work or suck, and most people give up after Labor Day anyway, just in time for the season premiere of The Bachelorette. (FYI: She's on Pinot and apples diet.)

If you were hoping the effect size or p values were going to guide you would have been lead astray. Those p values aren't telling you anything useful, they are at best confusing and at worst misleading. A glance at the methodology has more practical value than the little asterisk above a score at month 6.

Look at that stack of studies a meter high. I've just fed them to a goat. Tasty. Can you use them to say whether you should take lorcaserin? Whether Atkins was better than conventional diet? Can you use them to guide your decision about whether you should eat more bacon or more ice cream? Nope. And they will never be able to, because the purpose of these studies is not to determine the answer, the purpose of these studies is to be published, truth be damned.

So I'm sticking to bacon. And getting my sugar from you know what.

----

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: How Do You Treat Atrial Fibrillation?
It could be important...

Say you have a patient with a history of two heart attacks. That's bad. Now say he has atrial fibrillation. That's worse.   Now let's say he is on no meds.
What do you do? You'll treat two distinct problems: the history of ischemic heart disease gets a beta blocker, which has been shown to reduce mortality and improve quality of life. A-fib gets amiodarone, the generally accepted treatment.
Atrial fibrillation is a very fast but erratic twitching of the atrium. While a-fib can be annoying-- palpitations, anxiety, etc-- it is a major cause of embolic stroke; the uncoordinated flapping of the atrium leads first to blood stasis in a less moving part, then flicking off of clots which happily go to your brain. Hence, anticoagulants are common.
Beyond this, treatment of a-fib can be divided in two parts: rate control, with beta blockers, or rhythm control, with drugs like amiodarone. The question is, which is better, and which is safer? Traditionally, amiodarone was thought to be more efficacious.
Before I give you the answer, I want you to be aware of the form of the question. The question requires that you see a-fib as a distinct (disease) state, where risks and benefits of its treatment are considered. It is, analogously, "what are we going to do about John's left arm? It's a big jerk, always punching people. Is what we do going to work? Is it worth it?"
A study in the NEJM pitted sotalol, a beta blocker, against amiodarone for the effiacy and maintenance of a-fib.
What they found was, as expected, amiodarone was the best:

(The curves are read as "what are the chances you remain symptom free at x days?" People are all symptom free on day 1, so the chances are 100%. As time goes on, you get sicker. So at day 600, you have a 10% chance of being symptom free on placebo, but a 70% chance on amiodarone. )
What was surprising is what's best if the patient has ischemic heart disease along with a-fib:

If you have ischemic heart disease, sotalol was as good as amiodarone. And, presumably, a beta blocker is less toxic than amiodarone (though the study did not show this.)
But there's a further point to be made here, about information bias. Since beta blockers are already standard of care for any patient with ischemic heart disease, it doesn't actually matter whether they have chronic a-fib or not.    The history of ischemic heart disease is more important-- singularly more important-- than the a-fib.
So the guy above only gets a beta blocker.   Think about this.
Whether he had "regular" ischemic heart disease, or ischemic disease and atrial fibrillation, the treatment is the same, single, drug.
This is entirely the opposite of what happens in psychiatry. In psychiatry, we pay lip service to a "disease state," but end up treating each disorder as if it was separate. So a schizophrenic with negative symptoms (apathy, anhedonia, amotivation) gets an antipsychotic and an antidepressant, even though the antidepressant probably isn't necessary. It may seem like both are necessary, but that's because you gave them both at the same time. How can you know which was relevant med? Bipolar is worse: a "mood stabilizer" and an antipsychotic and an antidepressant (or Lamictal) each for a different symptom. The nod to "disease state" however, is the dangerous one: all the meds are continued, even though each was started for a specific symptom that resolved.
And, this does not even begin to account for the overlapping pharmacology of many of the meds (like giving two antipsychotics for different "symptoms." )
In psychiatry, the incidental gets as much attention as the substantial. But it is so hard for people to step outside themselves and say no to medication overkill.
This impulse towards polypharmacy- shotgun symptom management-- will never change unless there is a financial incentive, or, more accurately, negative reinforcement. And I have one: give doctors a medication budget per day per person.

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===== ====== ===== The Last Psychiatrist: How Not To Meet Women

and so man invented mermaids

A diversion:

As I was writing this, in a bookstore, a twenty something woman approaches a table two away from mine. Next a man approaches, and he chooses the table that is in between mine and hers.   For the next fifteen minutes he pretends to read a book. He may as well be eating a plate of spiders or playing with uranium, it is impossible not to focus on him, his nonchalance is tremendously distracting.

But the woman doesn't notice him. She is engrossed in her magazine and soup. That is the lie he is telling himself.

Of course she noticed him. She noticed him as soon as he walked in. Why do men assume pretty girls have visual field defects? Hope. The fact that she hasn't looked up at him is evidence that she noticed. She doesn't dare reveal it.

I've seen this movie before, and I've also seen the sequels. What he should do, if this is the suicide mission he wants, is to walk up to her early on, "hi..." and do his audition. Then she could either ask for his headshot or tell him she really likes his work but she's looking for someone who can play younger and less gay. But he doesn't audition, Instead, he stalks her for the duration of her tolerance. There's no other thing in the universe we get this way, not a job or food or airplane tickets, but somehow sitting at a table and not not looking at someone is somehow magically supposed to somehow result in anal. (Woah, that was jarring.)

I can't focus on either my computer or my sandwich, I am certain she can't either. But she's trapped in herself, too. She can't read her book and she can't get up and leave because it would be too obvious why she was leaving and she has that middle class guilt of making people feel rejected "for no reason." So we three sit, each pretending we're not aware of the others. None of us gets anything accomplished (well, this.)

How long you wait before your audition is inversely proportional to how much she wants to talk to you. Read that again: not will be-- is. That's quantum mechanics.

II.

So how's a modern woman supposed to politely decline the advances of a future parole violator? If you say, "I just want to read my book," it's easily taken as an insult by comparison, "what, I'm not more important than a stupid book? Who knew sluts could read. Oh, it's Vogue and you're just looking at the pictures. Dumb whore." (Hey wildman, easy...)

A good rejection can't leave room for comparison. For example, what she could say is, "no thank you, I just came because I need some time alone." A neutral, soft, non-ego threatening dismissal. You don't know what's going on in this woman's life, something, but whatever it is it was enough for her to want to be Alone. Ok. No one, least of all the most pathological narcissist, will argue with the logic that self takes precedence over non-self.

And this dismissal can also yield important information: anyone who doesn't respect the message is probably registered in a database, because it always means: "well, my self is more important than your self."

III.

"Hold on, Backbeard, I don't know what kind of women you have trapped on the quarterdeck but how do you know she isn't nervous herself, and wants you to come over?" Stop it. You're going to meat [no sic] your future wife in a bookstore with an unrehearsed cold approach, Cat's Cradle, and a triple espresso? Really? Has that ever worked for you before?

"Well, no, if I'm being honest I just want to sleep with her." Well, ho me wench. You're that guy? Take a look at yourself. You're so smooth you can operate in daylight?   Sober? And she's sober? You know there are security cameras around, right? You think you're going to lay your ycombinator rap on her?

"Well, some people can meet a girl in a bookstore." NOT YOU. "It worked one time." Then you didn't stalk her, did you?

I don't blame the guy for being nervous, I blame him for thinking he can bend reality to his will.   Figure out what kinds of environments you are good in, think where are the types of women that are right for you, go there. Being good at football doesn't mean you are good at soccer. Or dancing. Or Spanish. Ask Chad Ochocinco. "But I like soccer!" Stop it. No one likes soccer.   Don't do this to yourself, or to some girl who will add the construct of you to her Fiend Folio and ruin it for the next potential soccer player who wants to audition/register. Oh, have I placed metaphors where they don't belong? Exactly.

Don't torment and punish yourself with things you don't really want anyway. Things you want for the wrong reasons.

And don't do it in public. We're all trying to eat here.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: How Not To Prevent Military Suicides

bear

If you had a a family member commit suicide in the military, then please do not read this post. It is not for you, and running back over it all, wondering what was to blame and whether there was anything anyone could do is masochism, you will not find anything comforting here.
Probably the only consolation possible:
Now there is one thing I can tell you: you will [eventually] enjoy certain pleasures you would not fathom now. When you still had your mother you often thought of the days when you would have her no longer. Now you will often think of days past when you had her.
When you are used to this horrible thing that they will forever be cast into the past, then you will gently feel her revive, returning to take her place, her entire place, beside you. At the present time, this is not yet possible.
Let yourself be inert, wait till the incomprehensible power ... that has broken you restores you a little, I say a little, for henceforth you will always keep something broken about you. Tell yourself this, too, for it is a kind of pleasure to know that you will never love less, that you will never be consoled, that you will constantly remember more and more.

I.
For the rest of us, this is how you don't reduce military suicides.

Military suicide prevention efforts fail: report

Here are the cited reasons:

Each branch of the services rushed to create a suicide prevention program, but there was no coordination.
prevention training often failed because those running the sessions did not understand their importance
"It is not just the perception that they will be treated differently or somehow that it will affect their career, but it is also distrust in the system and distrust that mental health professionals can help them"
"A large percentage of our servicemen, our veterans, do not come in to get help"
"They don't trust us. They believe we speak with forked tongues," Bradley said.

Or, the conclusion of General Peter Chiarelli, vice chief of staff of the Army, before the Senate Armed Services Military Personnel Subcommittee:
"I think it is the cumulative effect of deployments from 12 to 15 months"
Of course: war is hell, and sometimes it's too much for some people. Right?

II.
You might think that would be the last thing a general would say, especially since deployments are scheduled to get longer.
And there's a substantial political desire for it to be true, to have yet another reason to end the wars. I don't blame them; nor am I saying I wouldn't similarly manipulate the truth if I thought it would save lives, but I don't lie to myself. You keep two books, not no books.

III.
Here's the important part of the data that is usually not included, not here or here or many other heres: 30% were deployed, 35% were post-deployment, and 35% were never deployed.
Those three populations are totally different. Whatever it was that happened in battle could not have happened before you got to the battle. This suggests that the approach for the never deployed be different than the currently deployed. Duh?
Second, in showing the official conclusion of the military, you might ask what they don't want the answer to be. In other words, not what is the benefit from this being the answer, but what is the benefit in it not being something else.   And that something else is physical traumatic brain injury.
And now we're into a longstanding, very real, military question: what is PTS(D)? Is it all physical, all mental, or both? What about mild traumatic brain injury-- all concussion, more than concussion, what? You can get "treatment" at any VA hospital regardless of what you call it, and (hopefully) doctors will look at the MRIs or the psych scales and treat what they need to treat, but the military won't formally call it anything until the money side is worked out. That money side is Congress's willingness to cover disablities and liabilities, and that willingness is entirely dependent on the reaction of the voters to the price tag. In other words, whether the suicides are the result of psychiatry, neurology, biology, divorces or explosions depends mostly on you.

III.
Here's a first step: take the management of suicidality in the currently deployed combat soldiers out of psychiatry.

What do you want to do here? Is the goal to reduce suicides or is the goal to "offer services" and "promote awareness?" It doesn't matter if suicidality is 100% genetic, you approach it like it's not.

Here is a statement, your reaction to which will quickly determine your interests lay: the only thing less effective than telling these soldiers that the solution is psychiatry is to add that the psychiatrists are all gay. Pray on this.

If we're pretending these psychiatric illnesses are real medical diseases, then we must defer to the patient's prejudices. And, my experience: soldiers don't like shrinks unless they're trying to be ex-soldiers, and then they only pretend to like us. And they don't trust that shrinks are not a sandwich away from going Columbine themselves, not least because one of them actually went Columbine, well after we were supposed to be "aware" of the "causes" of Columbine, and none of the other psychiatrists noticed.

Some of them maintain themselves on bravado and denial, they think that if they get their arm blown off in a fight, they're just going to special forces everybody down with the good hand.   Why would they admit to a mental illness, even if that's actually the problem?
You most emphatically cannot tell them that depression is a real medical illness with biological underpinnings that can affect anyone, from the Denver housewife to an Airborne Ranger, because you cannot make a soldier feel that his situation has anything in common with a Denver housewife's. At all. Because the more he believes you the more he won't show up.
It's revealing that the conclusion everyone has reached about these suicides is that "war is hell," yet the proposed solution has nothing to do with war. It more closely mirrors the kind of management I give a man traumatized in a waverunner accident. Are they similar?
Hence, the way to approach suicide prevention is to make suicidality/stress a rare, though entirely expected consequence of battle.   Not to over analyze it, but to acknowledge it. In short, not to pathologize it, but to mainstream it: "Yeah, me too."

IV.
You can stop sending more psychiatrists: 40% of the suicides are already in treatment and on meds. In regular America, only 25% of suicides have never seen a psychiatrist.
But if only it were so easy. Here are three factors that make military life nearly unbearable, that we don't hear about:
One: deployed soldiers are still in contact. Not only do they have the stress of war, but they also have an almost real-time update of the stresses at home. In Vietnam your wife wouldn't bother to mention the boiler broke down, now you get to know that fact the same day you shot/got shot by 6 people. You are doubly burdened and doubly powerless. Not to mention get to watch your marriage deteriorate in serialized emails while you're statused about her increasing happiness through facebook.

Third: 2% of the Army's drug screens come back positive. 2%. Includes Afghanistan. Where they invented heroin. 2%. Even as 25% admit to abusing-- not using, abusing-- painkillers.
Fourth: gangs: it's not the crimes, but the hostility, the fear and the marginalization. Try being an enlisted guy on a carrier looking to use the gym. Want to know what movie ordinary Army life isn't like? The Hurt Locker. What it is it like? Training Day. I'm exaggerating?

Those are bazookas.
Those are gang signs.
Those are women.

V.

Psychiatry may be the way to handle the non-combat suicides, but it clearly isn't working for the combat/post- combat PTS(D) group. So there's this:
Here's what PTSD is like, and why people kill themselves over it. Think of life like a cave. If I send you into a cave with a lantern and tell you there are no bears in the cave, you feel safe. You will walk around the cave and enjoy yourself. Now what if I give you a lantern and a gun and tell you that there is a bear in there? You can still go down, but you'll be careful to look for the bear and ready to run or shoot if you see it. Now, what if I send you down there with a gun but no lantern and simply say "bear" to you? Pretty soon, you're in there, you can't see the way out, and every rock you bump into feels like a bear. After a long enough time being down in the cave, you realize you don't have enough ammo to shoot everything that might be a bear. It has nothing to do with running out of food or water or feeling like you're fighting some unwinnable battle with the bear. You just get sick and tired of the uncertainty. Are you going to live through the night? Are you going to wake up to a bear gnawing your intestines? You get to the point where you just wish the bear would come along and end it. And when he doesn't come, you decide to do it yourself.
Couple that with a winning facebook update, and you're set.

---

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===== ====== ===== The Last Psychiatrist: How Seroquel XR Works, Part 1
When evidence based medicine results in a government sanctioned lie.

1. What is the clinical data on Seroquel's efficacy as an antidepressant?

In order to get an indication, the FDA requires at least 2 randomized controlled trials. Both were identical in design, and nearly the same in outcome.

Patients who were on an SSRI or SNRI, who were not improving after 6 weeks, were randomized to the addition of Seroquel XR 150mg/d, 300mg/d or placebo (along with the maintaining of their previous antidepressant at previous dose.) The results:

On the basis of this, and the other similar study, the FDA approved Seroquel XR as an adjunct to other antidepressant in MDD.

2. Is this a function of its antipsychotic properties?

No.    At 150mg/d there is very little D2 blockade; and not all antipsychotics have been able to show efficacy as an adjunct in MDD. Some other mechanism is likely.

3. How is Astra Zeneca and the FDA explaining the efficacy?

Not an easy question to answer. Any proposed mechanism must be accepted by the FDA; once a mechanism is proposed and placed in the package insert (and promotional materials), it cannot be changed without resubmitting to the FDA-- even in the face of contradictory proof. For this reason, e.g. they are vague on the mechanism in schizophrenia:

All of Seroquel XR's promotional materials, the package insert, and the clinical trials describe the efficacy as the result of Seroquel's effect on norepinephrine and the NET.

4. What is the evidence for the proposition that Seroquel's antidepressant effect is mediated by norepinephrine?

Quetiapine is partially metabolized to norquetiapine. Any pharmacologic (i.e. receptor) description of the Seroquel's effect must therefore include norquetiapine.

Quetiapine does not bind to the NET; but norquetiapine, its chief metabolite, is a potent inhibitor if it. Tricyclics, Effexor, and Cymbalta all have considerable NET inhibition as well. It's logical to conclude that when you eat a Seroquel, and it gets metabolized to norquetiapine, that it would then exert some action on the NET.

5. At a clinically relevant dose of Seroquel, how much norquetiapine is there?

Not much.

The package insert states:

The Cmax and AUC of norquetiapine are about 21-27% and 46-56% of that observed for quetiapine.
Or, graphically (from Winter J Child Adol Psychopharm 2008):

Levels of norquetiapine did not differ IR vs. XR.

6. What amount of NET inhibition occurs at 400ng/ml? Show your work.

300ng/ml= 300ug/L

300ug/L= 0.0003g/L

MW norquetiapine = 295.4 g/mol

0.0003g/L x 1 mol/295.4g = 1.02e-6M = 1015nM

Norquetiapine's Ki for the NET inhibition is between 12-35 nM, depending on in vitro or in vivo.

At clinically relevant doses, the NET is more than completely occupied.

7. Wow, really?

No, not really.

It appears that, in contrast to the longstanding paradigm of post-Kohut modern psychiatry, there is more to the human body than serotonin and norepinephrine receptors. I'm as terrified as you are. I don't know what to believe anymore.

A study measured the NET occupancy to Seroquel and norquetiapine (administered independently) in monkeys after a single dose. Norquetiapine produced 80% occupancy of the NET at low concentrations.

However, in the nine suckers induced to participate in this other study, 300mg Seroquel XR for 7 days generated 300nM concentrations of norquetiapine (as predicted above) and 35% NET occupancy in the thalamus. 150mg Seroquel XR-- the dose at which it functions as an antidepressant-- resulted in 19% occupancy. That's not very much.

Consider that if Seroquel is metabolized to norquetiapine in monkeys as well, then a clinically relevant dose of Seroquel should produce clinically meaningful occupancy of NET (by the effect of its metabolite.) It didn't.

The actual occupancy of the NET after 300mg Seroquel XR is quite low, 150mg even lower.

8. Can you compare this to the occupancy of something I know-- like Effexor?

NET PET studies aren't as easy to do as DA studies, because many of the ligands used in the experiments bind nonspecifically and produce greater background binding. There's also not an obvious negative to compare it to (e.g. there aren't any DAT in the cerebellum, so that becomes your control in DAT experiments.) Radioligands specific for NET are only recently becoming used; Effexor doesn't have available PET data because now that there are such ligands for use in a study, Wyeth doesn't exist to pay for them. Take that, unbiased research.

Understanding that the comparisons are not entirely fair, a blood assay in depressed humans found that after 8 weeks of Effexor 150mg, NET inhibition was 50%. At 375mg, it was 60%. Paxil, an "SSRI", blocked about 30% at 75mg. Note that Effexor is only 55% protein bound (Seroquel is 80%) and thus in a real patient, there is more free Effexor to exert activity on the NET, which may be why it has such a larger effect on the NET despite a theoretically weak Ki (2200nM).

Despite this, the NET occupancy of a clinically efficacious dose of Seroquel XR (150mg) is likely too low to be the main cause of its antidepressant efficacy.

Part 2 here.

===== ====== ===== The Last Psychiatrist: How Seroquel XR Works, Part 2

The ongoing story of a government cover-up

Part 1 was here.

Let's assume it did bind to the NET, how much of the efficacy should we attribute to norepinephrine?

In the pre/frontal cortex there are no pure dopamine transporters (DAT), and the NET is primarily responsible for dopamine's reuptake. So the NET, which norquetiapine fully occupies/barely touches, transports about 50/50 norepinephrine and dopamine.

So even if the NET is inhibited, the ultimate effect in the frontal lobe may be related to dopamine.

Are there any other better explanations for Seroquel's antidepressant efficacy?

It's odd that while the FDA has chosen to be unsure about the mechanism of action in psychosis, it is confident in the MOA in depression. Here are some equally/more likely explanations for the antidepressant effect:

H1 antagonism: sure, why not? 6 points on a Hamilton for sleep, another 2 for weight gain...

Partial agonism at 5HT1a: Think Buspar.

a2 antagonism: (inhibitory autoreceptors.) Blocking these would increase serotonin and norepinephrine release, etc.

Unfortunately, a2 antagonism is a property only of quetiapine, not norquetiapine.

Why is that unfortunate?

Because if norquetiapine is marketed as a new drug...

But if norquetiapine does actually inhibit the NET, wouldn't that at least be a plausible mechanism for its efficacy? Since Effexor and Cymbalta work...

I'll grant that it is evident Effexor and Cymbalta work; but who are you asking to tell you why they work? Wyeth and Lilly? That's like asking your future wife's ex-boyfriends to write her a letter of recommendation. "She's so awesome, she'll make you really happy." Oh, I guess I should go shave my back then.

That's a very disturbing visual, Backbeard.

Let's do an abbreviated analysis for Effexor. According to this non-porn site, the Ki for the SERT is 80nM and NET 3000nM (1000-6000). This means it "prefers" to go to the serotonin transporter (SERT).

Consistent with this is PET data showing high SERT binding in striatum:

This is a comforting graph, and shows the "fountain" approach to understanding a "dirty" drug's effects. But note that the line isn't flat, it still trends upwards. If the affinity for the SERT is 200-600 times that for NET, then clinically meaningful effects on NET would have resulted in serotonin overload.

But that's speculation. You've already shown that the Ki's are unreliable guides of in-vivo affinities and effects.

Ok:

What you want is a direct test of the operation of the NET in the human body.

If you inject tyramine into your friend, it will be taken up into the presynaptic NE terminal by the NET, where it will cause the release of norepinphrine. The blood pressure then reliably goes up.

If you block the NET, this effect will also be blocked, since tyramine can't get in. Nortriptyline, a tricyclic and "norepinephrine reuptake inhibitor" blocks the tyramine effect almost completely.(1)

What about Effexor? If Effexor is an NRI, it should also block the blood pressure elevation. Zoloft, not an NRI, should not block it-- the BP should go up.

This is ratio of post/pre blood pressures; >1 means tyramine caused BP to go up, <1 means tyramine couldn't get BP to go up.

What you see is that 75mg of Effexor was no more an NRI than Zoloft; and maprotiline (the NRI) turned Effexor 375mg into a cuckold.

But surely Cymbalta has impressive clinically relevant NRI effects?

What dose of tyramine is needed to make the BP go up 30mmHg? That's called the PD30. If a drug blocks the effect (like desipramine, an NRI, would) than it would take more a higher dose of tyramine:

TYR PD₃₀ (mg)
Day 7 Day 8
Placebo (n=12) 7 [4-14] 6 [5-9]
Duloxetine 80 mg (n=5) 9 [5-8] 7 [4-7]
Duloxetine 120 mg (n=6) 6 [5-9] 4 [4-7]
Desipramine 100 mg (n=11) 30 [22-82] 18 [12-31]

Well that's unfortunate. (2)

But then how can they claim Cymbalta is an NET?

1. By ki, the SERT/NET ratio is about 10, versus Effexor's 200, so in that sense you get the norepinephrine "earlier" in the dosing cycle;

2. If it blocks the NET, then it should also decrease the cycle of norepinephrine turnover (since it isn't being taken back up and degraded.) So there should be less NE and its metabolites in the urine. And that's certainly what this study finds (abstract:)

Urinary and cardiovascular measurements suggest that duloxetine has an effect on NE synthesis and turnover, indicative of NE reuptake inhibition.
"Suggest?"

Compare the NRI desipramine (DMI) to placebo, note the decrease in urine NE and metabolites. You can see that while the levels of NE and its metabolites decreased in the urine, Cymbalta resulted in a decrease in only the metabolites, but not NE itself. Do you know why? No one else does either.

On the basis of this study we can reasonably conclude only that duloxetine is spelled with an x.

So you're saying that they arbitrarily decided on the mechanism of action of Seroquel by its barely detectable similarity to Effexor and Cymbalta, which themselves don't generate their efficacy the way they say they do and Seroquel hoped they did?

At this point, someone in the room should probably say "oops."

-----

Part 3. (You mean there's a Part 3?)
----

1. One interesting conclusion of this is that it would therefore be safe to mix an MAOI with Pamelor. THAT IS NOT A CLINICAL RECOMMENDATION.

2. If you want to make a gazillion dollars, perform the TYR30 test with Seroquel and norquetiapine. Residents: I just gave you a treasure map.

===== ====== ===== The Last Psychiatrist: How To Be Mean To Your Kids

stabilize the price, whatever it takes

A reader sent me a link to an article written by psychiatrist Steve Balt, How To Retire At Age 27, in which he describes a typical patient in his practice, a 27 year old named Keisha:

During the interview, she told me, "I just got my SSDI so I'm retired now." I asked her to elaborate. "I'm retired now," she said [boldface in the original]. "I get my check every month, I just have to keep seeing a doctor." When I asked why she's on disability, she replied, "I don't know, whatever they wrote, bipolar, mood swings, panic attacks, stuff like that." She had been off medications for over two months (with no apparent symptoms); she said she really "didn't notice" any effect of the drugs, except the Valium 20 mg per day, which "helped me settle down and relax."

I misspoke when I said "typical patient." She's slightly unusual for his inner city population, because she actually graduated high school and even took nursing assistant classes.

She dropped out, however, because "I got stressed out." She tried looking for other work but then found out from a family member that she could "apply for disability."

A psychiatrist and a lawyer later and she's awarded a pension of $700 a month. No retirement party, though. And she'll have to buy her own watch.

The rest of his post is a thoughtful back and forth about what constitutes disability, and whether a) giving them this easy way out isn't actually doing a disservice to the human being in front of you; b) whether these false diagnoses aren't artificially inflating disease prevalence estimates; c) the extent to which it contributes to bureaucracy (and cost.)

II.

So when he emailed me the link to the article, How To Retire At Age 27," the reader asked me a tongue-in-cheek question: "Now why didn't I think of that twenty years ago?"

Thing is, he probably did think of that, or some brief fantasy of something like it, but figured he could make much more money doing something else. Therein we have the problem:

Evidently, this woman Keisha doesn't think she could make substantially more than $700/month doing something else, so regardless of whether she is truly disabled or not, her conception of her opportunities is seriously limited. That's social policy problemo numero uno.

Note that she even took classes to be a certified nursing assistant, and still doesn't think it's worth it. So either CNAs don't get paid enough (over SSI) to merit giving up all your free time to work with the belligerent poop machines at the hospital, or else SSI pays too much to make that decision even worth considering. There are no other possibilities. Choosing between those without sparking riots is social policy problemo numero dos.

Then there's a subtle semiotic issue. She calls it "retired." Not disabled, but retired, which means in the language of social policy she has understood that she has somehow "worked"/contributed to society to merit some retirement benefits, and also tacitly accepts she's not unable to work, rather that she's done working. So what could she have done to merit retirement? The answer probably is nothing. Right? But no one has tried to correct her thinking about this because, well, it just isn't worth arguing with some unemployed black woman at a psychiatrist's office because you'll be branded uncaring and racist, not just by her but by some other busybody with a progressive agenda, free time, and a government/media job.   You will also likely get punched. Besides, you and anyone who values work as a moral good and an end in itself don't have time to explain it to an unwilling Keisha, you actually have to get back to work. So she's left with her comforting lies that go unchallenged-- bellay that: they are encouraged. That's social policy problemo numero tres.

III.

But now we have to take three left turns to get at the truth.

There is a significant misconception of what "disability" means, and I'm not going to say what you think I might. Dr. Balt, and I'll wager most people, think Keisha is probably able to work. However, the issue isn't whether she can work, but whether any employer would be willing to take a chance on her ability to work. Would you hire Keisha to run your office? Do billing? In the spacious comfort of an internet comment you might hire a woman like Keisha to work at a hypothetically inefficient McDonalds, but in practice, are you willing to tolerate "3-4 absences a month due to illness?" McDonalds neither, which is why the SSI application form asks that exact question.

You will observe the Keisha does not even have the enthusiasm to know what is written on the most important economic documents of her life. "I don't know, bipolar, panic attacks, whatever they put on there." She can't be bothered to handle those papers, someone else is in charge of that. How attentive will she be to the frier? McDonalds doesn't want to find out.

That specific issue reveals an important bias and misunderstanding America has when it talks about employment. Yes, there is an issue about people wanting to work but the other issue is that the global economy is too quick and efficient to tolerate your idiotic car troubles or your imbecilic grandmother's death or your moronic lack of child care (cue Scandinavia) or, and mostly, your stupid health. The economy was a Ferrari and now it's only a Honda, but either way, not much time for absences and no time at all for Keisha's learning curve. Keisha isn't just unemployed, she is completely unemployable.   We can argue whether auto plants should pay $20/hr or $50/hr, but for certain there is no market for unskilled labor at all.   Let me correct another grand mistake of the politicians and the talking heads in the media: this problem is likely to get much, much worse, not better, as the economy improves. There are no typos in that sentence.   Read it again.

The jobs employers would be willing to take a gamble on are jobs that pay too little for it to be worth her showing up at all. Hence SSI. Sure, maybe you could work at Walmart for $7 an hour but they don't offer benefits so ultimately, what's the point? A rich guy may think he pays his Mexican housekeeper good money, but the fact is if Juanita doesn't show up one Tuesday morning he doesn't miss a step, which is why he was willing to hire her. You send the suits to tell him he has to hire her legally, pay her wage taxes and offer her health benefits and still take the risk she doesn't show up and he'll release the doberman on you and just hire four high school kids to each work a block of two hours a month. Is that fine with you? Then go see what Juanita's next step is.

All of this comes down to a very important point: the country's economy understands these issues on an unconscious level, and it has created a system to absorb 10% of the unemployment, i.e. pay them off so they don't riot, exactly like Saudi Arabia buys off its people. Yes, America is a Petrostate, but instead of oil money it's T-bills. However, as is evident throughout history, rich white people riot too, hell, they'll overthrow a King because the rum prices fell too much or shoot a President because he wanted a third term; and they'll for damn sure John Galt the Senate if they think poor people are getting free handouts, so the system pretends to offer benefits based on medical disability, just as it pretends on your behalf to be appalled by Mexican illegal immigration even as every restaurant in Arizona employs illegals, and everyone knows it, including the politicians and the Minutemen who eat at every restaurant in Arizona, not to mention California, not to mention America. Dummy, the sign says "Authentic Mexican Food"--oh, never mind.

For fun, let me point that that another 10% of the unemployed in America are relabeled as "incarcerated", so total you have a real rate of 15-20% unemployment, and this does not include the unemployable who have been relabeled as "military personnel" thanks to two endless wars, or those who manage ten hours a week at the Buy-n-Large who are relabeled as employed and thus are of no consequence; all of which is good because if the unemployment rate printed higher than "9%" the credit rating of the US would have to fall to C-. "But you need at least a 3.0 in your major to graduate." There's your grade inflation.

Psychiatry is the unsuspecting but intentional handmaiden of this process. Never once thinking it was being pulled into a long con, it self-righteously accepted its grownup label as "medical specialty" and began ostentatiously fighting for "mental health parity" and the Medicaid funds that it thinks it deserves, "we care about patients, about people!" And it comforted itself with the knowledge that 25 medications and nine academic journals must signify they are scientists, which means that all my Foucaltian ranting couldn't possibly apply to them. And yet, here we are. Dr. Balt is obviously earnest and even optimistic when he tries to articulate cause and solution to these social issues, and he's to be commended for seeing through the Fog Of Prozac; but, lamentably, he is too late for change to come from within psychiatry. Note that-- and this is neither an exception nor a criticism of him-- even though he sees this truth he cannot stop, he can't refuse to participate, and neither can I, or the other psychiatrists who are eyeballs deep in a system none of us conceived yet all of us are responsible for. The system has been vaccinated against dissent.

I can sense you pulling away from my abstractions, "that's all very clever and all that, but how does it actually work in real life?" This is what I'm trying to tell you: it doesn't work in real life. It only works in theory.

He closes, "Using psychiatric labels to help patients obtain taxpayers' money, unless absolutely necessary and legitimate, is wasteful and dishonest." Maybe, but if you change the system he will lose 100% of his "patients"; and never mind him, you do not want to know how the system will relabel the patients when that happens, or who will be in charge of that relabeling. I am sure he will not believe me. Fortunately for him, he will never have to find out.

IV.

And this brings us to the essence of the problem, of all of the social policy problems that we currently face. "How did this happen? How did it get so bad?" The answer is that it has always been this bad. We didn't care.

Narcissism has been on a steady rise since the end of WWII and went parabolic in the 1980s; all social policies have to be understood in the context of that psychology, that culture. Hence SSI isn't altruistic but narcissistic, its every (no sic) purpose was not to serve others but to serve us.

Stop thinking of SSI as money. SSI isn't taxed, and if you recall the First Law of Harbors, "taxation=representation": not taxing them is the same as not giving them representation. So for $700/month they don't call you to account for all the rest of the money. "Yeah, but don't they vote?" HA! You kill me. I meant actual representation: lobbyists.

As long as they-- and the inmates and the etc-- are munching on food stamps, weed, and Xboxes, nearly illiterate but keeping their nonsense within their neighborhoods, the rest of us can go on with our lives. Which means that every unconscious force exists to keep this state of affairs going until we no longer need it. And if that requires printing money or releasing oil reserves to keep prices down or insisting there's a shortage of psychiatrists, "how about some NPs?", so be it, because the system must be preserved, including and especially at the expense of the future. It's a popular political refrain that Social Security will soon be bankrupt, but that's meaninglessly obfuscating: it won't be around for the kids when they grow up because it wasn't for them, it was for the people who were around when it was conceived.    There was never any way it could last forever, no credible way of funding it-- especially the moment productivity went parabolic compared to wages.

you don't have to be a labor theorist to recall what else went parabolic at the same time

Don't say that taxes needed to be higher because it was never about funding it, it was always about temporarily buying their apathy. Truth be told, it stayed solvent longer than it was supposed to-- one of the benefits of having a reserve currency, aka a private meth lab. But you knew that, didn't you? Temporary measures, just like a psychiatry that is for the "management of acute symptoms"-- or are you going to tell me you expect/want it to look like this in 30 years? Then why is it like this now? And so this is the terrible, awful truth of it all: we created the system only for us, and will last for as long, but only as long, as we are alive, and that was as far as anyone ever thought it out. That means that any kids under 10, rich and poor, will be left to make do with rubble-- on purpose.    That's what they will inherit from the Dumbest Generation Of Narcissists In The History of The World, who say with not the least bit of irony, "may as well spend it because you can't take it with you!" No kidding. You've created a gigantic Ponzi scheme which is not just morally sketchy but downright mean to your kids, but what do you care: you'll be dead.

In some Bible story Ford Prefect warns the humans, "two million years you've got and that's it, at the end of that time your race will be dead" and he meant it as a fait accompli but that was a guy who took the long view; and when the response came back with a soothing smile, "well, still time for a few more baths!" that was a guy also taking the long view, the difference being his long view was exclusively to justify his present frivolity. It should be no surprise that this second guy's brilliant solution to a fiscal crisis was to call leaves legal tender and then burn down all the forests. They didn't survive the winter. But the warning I offer the younger generations who have to clean up our messes even without the benefit of forests or a functioning psychiatry is what consequently happened to the first guy: he went mad.   It is inevitable.

----

Previously: The Terrible, Awful, Truth About SSI

===== ====== ===== The Last Psychiatrist: How To Create: Motivation for 2010

he didn't finish it either

This is what's stopping you:

1. The fantasy workspace.

All artists-- and probably all people-- have in their minds the fantasy workspace. "If I could only work in..."    Forget it. This is always going to fail. Always, every single time.    They are distractions, they sap emotional and creative energy. You may be surprised to learn/assumed that this blog is written mostly in airports, hotel lobbies (wifi), and on my Blackberry.

Here are some famous authors' spaces.   At first glance you might say, cool! but look closely, these are basically cluttered (or bare) offices and areas. They're created out of ordinary necessity. They weren't set up, they evolved over time.

You may try to wave this photo at me:

"Look, he's writing in his fantasy studio." Really? 20 books, with a fountain pen and oil lamps? I investigated:

Real life at home follows a fairly consistent pattern. I get up between three and four in the morning and brew a pot of tea. In the cool months, I make a fire in the fireplace and sit down there to write. When it's warmer, I go out on the back porch. We live on the edge of a few hundred acres of pine forest, and it's pleasant to have the trees and birds and animals out there in the dark while I work.
I do my first drafts in longhand, writing with a fountain pen into blank books. I like the freedom from machinery, and I seem to write more and faster that way than with a computer. It also gives me a definite first draft. Like most people, when I compose on a computer I keep jumping back and forth; by the time I print out a "first" draft, it's actually been worked over a bit... There's no electricity on the porch, so I write between two oil lamps -- making up stories about the distant future, using medieval tools.
Much of this set up is necessity, but in any case he doesn't do it for very long:
After I've finished about 500 words, I quit, and retire to the actual study, which is a book-crammed labyrinth of computer and office equipment.
He has a real study, but writes elsewhere to get the juices flowing. Worth noting that he started writing this way only after he had already published several books.
This is what you are thinking:
"If only I had those kind of materials."
"If only I had better canvas."
"If I only had the Glengarry leads."
"If only I was rich."
Then you'd fail. Creative success is taking what's available and rising above that. The "that" doesn't matter, you'll only be credited with success if you go beyond it. Maybe Picasso had good canvas but he had to transcend an entire way of painting, that's what made him great, not the physical painting itself. Otherwise we wouldn't be buying prints.
Stephen King, On Writing:

For years I dreamed of having the sort of massive oak slab that would dominate a room.... In 1981 I got the one I wanted and placed it in the middle of a spacious, skylighted study... For six years I sat behind that desk either drunk or wrecked out of my mind.... A year or two after I sobered up, I got rid of that monstrosity... got another desk -- it's handmade, beautiful, and half the size of the T. rex desk. I put it at the far west end of the office, in a corner....I'm sitting under it now, a fifty-three-year-old man with bad eyes, a gimp leg, and no hangover....It starts with this: put your desk in the corner, and every time you sit down there to write, remind yourself why it isn't in the middle of the room. Life isn't a support-system for art. It's the other way around.

2. Not starting.

A common piece of advice is "just start!"/don't procrastinate, etc.

Let me explain, however, why this is a cognitive necessity.

No matter how carefully you plan something in your mind-- work through details, procure materials, etc-- it can't take into account everything that happens. Try imagining having sex with Paz de la Huerta; and then try actually having sex with her. The first is masturbation, the second is very tricky, although rewarding, business.

Every creative idea is a dialogue between you and yourself (masturbation); every creative act is a dialogue between you and reality (sex.) You can't account for that other half of the dialogue until you begin it.

Reality takes many forms: the light of a computer screen, the need for the "great phrase" to be surrounded by words that are less inspired; hunger, the need to pee, fatigue, caffeine headaches, hangovers; relentless, crippling, blackening self-doubt. You can never account for these except through action. I don't mean they are necessarily obstacles-- they don't necessarily hold you back-- but the are real success of any creative act is that it transcended reality not by bypassing it, but by going through it.

Or you can just go back to masturbating.

3. "I need peace and quiet!" Not exactly.

In airports and wifi hotspots, I am constantly distracted, usually by women, occasionally by lunatics. However, I get a lot done there because both women and lunatics are scared of me and so I am rarely interrupted. Peace and quiet is valuable, but if every 30 minutes the quiet is interrupted by a phone call or your spouse asks you if you bought the ham, you'll get nothing done. Parents tell teens to turn off the FM radio so they can study better, but that act of telling them is far more distracting than two hours of commercial free Hot97. Sometimes, you interrupt yourself (check email).

This is likely the biggest obstacle to practical creation. Creativity takes inspiration from everywhere, but working on the creation requires concentration, mental focus. Interruptions block this. Imagine again, you are having sex with Paz de la Huerta, and your spouse interrupts you to ask if you bought the ham. Seriously, how are you supposed to work like this?

4. 90/10

You can do 90% of something, but the last 10% takes years, or never gets done. How's that novel coming? Almost done, I'll bet.

It's the same process operational in dating. Long term relationships that never quite make the obvious and natural step of marriage; or furtive glances in a bar that never culminate in an audition: "hey baby, before you got here I thought I didn't really want a blowjob. How 'bout some Jaeger?!"

All of those are the same thing: defenses. Abstractly, they are fears of finality. Not finishing means anything can still happen, your identity remains intact: "I'm a writer."

More concretely, they are a form of self doubt not about the success of executing the act which is in your control-- the writing of the book, the asking the girl out-- but of being able to manage the consequences which are not-- the publishing of the novel, sustaining a relationship/finding a burn unit.

5. Deciding to finish.

It's evident I am not a writer; but each post takes me hours to write, over days. I revise constantly, and still the result is-- well, this.    However, at some point I have to overcome my strong wish to revise again (and again and again) and hit submit. First, even though every revision takes the same amount of time, the improvement from subsequent revisions quickly plateaus. Second, unless I hit submit, none of the revisions do anyone any good at all.

I have to decide that it's finished. Read again: it isn't actually finished, I have to decide it's finished.   Creative acts require a decision to terminate (e.g. sex with Paz) otherwise it can go on forever.

Some creations, like a novel, are large enough that you don't notice you're avoiding termination. So break a big job into smaller pieces each with definite ends that exist reality.

Example: don't write the novel, blog the chapters. It worked for Dickens. The moment the first chapter goes out your relationship to the book will change. Not just due to feedback, but you'll also find out how much of the novel you really had in you; if it's really a novel or just an idea; if the novel is really a derivative of someone else's. Etc.

If you're scared of the feedback, turn off the comments. The important thing is to do something in reality, not in theory. You can procrastinate a single termination point, but it is very hard to avoid multiple, regular, termination points.

Even for losing weight: "I'm going to lose 10lbs by Valentine's Day"-- it's easy to cheat on your goals and say, "well, I'll just make it up next week." Try, instead, taking a photo of yourself in a bathing suit each week and putting it on the fridge. Or mailing it to me. Or putting it on a blog. Force the idea-- your goal of weight loss- to confront reality regularly, repeatedly, instead of once (at the end). You might say this is going to fail, but if this is going to fail, then you weren't going to succeed anyway.

Happy New Year. You're running out of time.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: How To Destroy A Marriage
This has nothing to do with psychiatry. Or maybe it's the only thing that has anything to do with psychiatry.

The writer of ShrinkTalk writes about an experience as a marriage counselor. He lists 7 reasons why marriage becomes difficult for some people.

He comes up with his reasons based on his experience with couples. Interestingly, however, all of those reasons are generally of the type "unrealistic expectations" or at least "the wrong impression."   In other words, the marriages failed not because of what went on in the marriage, but because people were oriented wrong before they even got married.

This may partially explain why arranged marriages or marriages "in the old days" lasted so long. Everyone knew precisely what marriage was all about, there were no illusions or confusions.

If this is true, than perhaps the role of counseling is to quickly reorient disoriented people's expectations; or, perhaps people should go into counseling before they get married in the first place.

I thought about this, and came up with my own observations, all of which are post-marriage accelerators of divorce.

Contempt.
This statement is 100% accurate: cheating on your spouse is less detrimental to your marriage than rolling your eyes, looking away, and saying, "oh my God, you're so annoying."
I'm not saying you can get away with cheating. But contempt in the marital interaction is the most important predictor of marriage failure; and, probably, those marriages should be dissolved as soon as possible anyway. No good will come of them.

Bring work home with you.
And I don't mean the quarterly reports.
You have another bad day at work, you come home and she asks about your day. You answer from a 15 year olds playbook: "fine;" "nothing;" "same stuff." And so she asks you to cut the carrots, and you snap. "God damn it!"
You've brought your suppressed work-emotions home, and you let them out on your family. Why? Because you can; you don't need to suppress at home. You're curt and irritable and withdrawn. Maybe your wife understands.   For now.
I know, it's hard to keep those emotions in check after your boss has been riding you all day. Yet then the UPS guy comes to the door and you are instantly nice, bright, warm. "Hey, thanks, have a good one buddy! Go Raiders!" You'll say it's an act, but the other way of looking at it is that you think it's worth faking politeness to the UPS guy, but not to your family. See? Does your family need to see the real, irritable you?
Oh, I hear you, my special, special, generation, the one that counts hypocrisy the greatest of all possible sins: "if I can't be myself at home, what's the point?" Because that isn't the real you, there isn't a you. Who you are is what you do. If you come home and are cranky and curt and bossy at home, then you are a jerk. You don't get to say, "I'm a nice person, but I just happen to be irritable every day."
Even if you aren't a jerk, what your family sees is a jerk.
Leave work at work; leave work emotions at work. They have no place at home, they are not useful and they serve no purpose. Of course you can talk about your crappy day, you can show her the schematics for the bomb you want to build. You can be angry at your boss, but don't be angry at your spouse because you can't get angry at your boss.

No time to yourself.
Self help guides get this wrong. They say that to preserve sanity, you need some time for yourself; they say new moms need some "adult conversation." That is counterproductive.
You rush through dinner, through clean up, through idle conversation ; you're checking off your "responsibilities" so that you can get a moment to yourself. The result is you are not there, you're passing through, emotionally, until you can get to what you think you want to get to.
Life is what happens while you're trying to get to the computer.
A lot of people are going to disagree with me, and they are wrong. First, understand that your family is all there is. There is no break, there is nothing else, there is no "adult conversation." It is possible you may never golf again.   The kids aren't the distraction-- everything else is the distraction.   If golf is a pleasant diversion that doesn't cause you to rush through family life in order to get to it, then it's ok. Otherwise, it's out. Otherwise you will be rushing through family life to get to course. And you will miss out on the family, and will still not get any real relief from golfing.
Once you have accepted this, you can then proceed to step 2: decide on two or three "distractions" you really like, and put them into your routine, with dedication and commitment. If you are truly committed to them, your spouse will understand (and they'll have their own.) But if you pick, say, going to the gym MWF, but you yourself aren't dedicated, it will appear to your spouse that you use it as an escape only when things get tough. (Because that's what it will be.)

Loyalty over truth.
This is going to be controversial: no matter what happens, your family is first. That doesn't sound controversial? Read on.
If I have a kid on the lam for a series of crimes he did coked up on heroin, and he asks me for some money to hide out in Uganda, guess what? I'm giving him the money. I may take some corrective actions; but no one else gets to.
I know this doesn't work within the framework of a just society, but I do not happen to believe we live in a just society. The only thing I do know is my family is all I really have. I may want to kill them, but you can't.
Knowing that many won't agree with that posture, I'll soften it a bit:
The same loyalty code applies to your discussions with outsiders about your family. No jokes at your spouse's expense. Ever. You never tell your coworkers about your kid's drug habit, or your wife's porn addiction, or that you wish your wife had a porn addiction. Certainly you have a best friend that you can commiserate with, but even within that relationship you cannot tell them anything permanently damaging. No facts, only feelings. For example, "my husband doesn't listen, he doesn't understand, he ignores me, etc" is ok on special occasions. But "my husband punched a window, he takes Zoloft, he has a shoe fetish, etc" is definitely out. Honor means: shut your trap.
First, it's disrespectful to your spouse. Second, more practically, it changes the other person's relationship to your spouse, and consequently to you. Telling your coworker you're divorcing your husband because he's sleeping with a cheerleader also tells your coworker things about you, e.g. "what the hell is going on in that house?" and "she talks a lot."

Communicating through kids.
If most of your conversations with your spouse are about your kids and not about each other, you're normal. If all of your conversations are about your kids, one of you is probably cheating.
Couples end up talking with each other, towards the kids; but not to each other, about each other. At some point you forget your spouse is an individual; you forget they had a past. You forget they have a future. All you know is that they are in your present.
Have you thought about what it will be like the day your kids go to college? Sure. Have you thought about what you'll do next? Sure. Have you thought about what your spouse will do next?   ("Be sad" means you haven't thought about it.)

Refilling Hedonic Supplies
See above. You know how most sleights roll off you because you have a fairly stable sense of self, and a stable position in your family? Awesome. Now the same should go for complements. Especially for complements.
You should say, "thank you" and move on.   If you find yourself flattered; or find yourself fishing for complements; then something is lacking at home which needs to be addressed, but more urgently you need to fix yourself that these complements have any power.
Remember the hot girl in high school, and you said to her, "I like your jacket" and she maced you? She did that because she doesn't need your complements, and immediately senses that you're only doing it because you want something from her. You need to adopt a version of this stance once you are married.
Every Lifetime Original Cheating Movie has the following line: "he made me feel alive again." I know, that's the problem. Your husband's problem for not making you feel alive-ish ordinarily; and your problem for needing that from someone else in the first place.
Marriage means: not having to look elsewhere for affirmation of identity.

----

I'm on twitter. If enough people sign up, I'll try to make it worthwhile.
http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: How To Draw (This Is Not An Article About How To Draw)

easier then it looks

"Some people have it, some people don't."

The New Drawing on the Right Side of the Brain: A Course in Enhancing Creativity and Artistic Confidence is a famous drawing book which uses the insights of neuroscience to improve drawing skills. (Here's how recent the insights are: the author's name is Betty Edwards.)
Nevertheless, this is an outstanding book that everyone should read once, regardless of your interest in drawing.
Given my awareness of the biases and cognitive shortcuts that make our lives easier yet sabotage us, I was surprised that I didn't naturally appreciate what makes people/me terrible at drawing: reliance on cognitive shortcuts, i.e. symbols.

If I were to draw a person, I would draw a circle, then two smaller eye ovals, a triangle nose, and double line for a mouth, then tubes for arms and legs. Hence, all my drawings look like they belong on a refrigerator. But that's "how I draw": head= circle, eyes=ovals, legs=cylinders. An example from a children's book I started a long time ago:

And cave=tunnel.
Edwards calls this the "tyranny of the symbol system" because it dictates to us, forces our hand to draw symbols rather than what we see.
But it isn't simply that we draw using these symbols; we perceive using them as well. I don't bother to see the actual shape of a head because it was never important to; in order to see it for what it really is, I need to practice my perception. It is easy for me to see a news story as a manufactured construct, but it never occurred to me I was seeing every day objects wrong. My tilted computer monitor isn't a rectangle; it's a trapezoid.

So "draw what you see" requires practice perceiving things correctly: without the aid of your symbols. So lesson 1: draw something upside down.

Focus on the lines, not on what you think it is.

Symbolic drawing also impairs depth perception, angles, sizes, overlaps. Hold up your hand and point your fingers at your face. How would you draw that? Five long tubes? But in 2D, they're actually irregular stumps.

To relearn perception, Edwards says to hang a piece of glass (or use a window) and place your hand on the other side, close one eye (finally, being a pirate pays off) and draw the outlines you see.

It will feel weird, because you'll want the pencil to go "in" to the glass. Instead, you'll have to draw the line in an unnatural direction that will feel wrong. But practice this exercise enough times and you'll see things differently all the time, you'll be able to switch back and forth between 3D and 2D and witness the impact of perspective in your every day life. Edwards includes the following letter from Van Gogh:
I remember quite well, now that you write about it, that at the time when you spoke of my becoming a painter, I thought it very impractical and would not hear of it. What made me stop doubting was reading a clear book on perspective, Cassange's Guide to the ABC of Drawing; and a week later I drew the interior of a kitchen with stove, chair, table and window - in their places and on their legs - whereas before it had seemed to me that getting depth and the right perspective into a drawing was witchcraft or pure chance.

II.

Though this is a book about drawing, Edwards includes the following quote from George Orwell:

In prose, the worst thing one can do with words is surrender to them. When you think of a concrete object, you think wordlessly, and then, if you want to describe the thing you have been visualizing you probably hunt about until you find the exact words that seem to fit it. When you think of something abstract you are more inclined to use words from the start, and unless you make a conscious effort to prevent it, the existing dialect will come rushing in and do the job for you, at the expense of blurring or even changing your meaning. Probably it is better to put off using words as long as possible and get one's meaning as clear as one can through pictures and sensations.

There is a controversy about whether language expresses thought or creates thought. I don't know. But I do know that language offers a feeling of certainty and masks ignorance.

Your explanation of why Obama or Bush are terrible Presidents are the equivalent of my drawing of a person, the difference is that you can see how my symbolic drawing results in a poor representation of reality, but you are unaware of how your explanations are just as primitive. Take a look at how many times you use a stock phrase or someone else's words ("in my opinion" "it's long been held", "tax and spend" "war of aggression" "fiscal discipline", etc). Cut those out and see what's left. But you'll use more words to cover your revealed ignorance. The problem isn't that you can't express yourself well, the problem, as in drawing, is that you did not perceive well. You relied on symbols, and they made you feel knowledgeable.

No surprise that many "geniuses" report seeing their tasks in two modalities, like the physicist who has a mental image of what the equations represent or the writer who hears his words as music. And when one is stuck at a thought or an emotion, it is helpful to translate pictures into words and words into pictures. (1)

III.

Next lesson: negative space. When you draw a chair, your mind is focused on the shape of the chair, but as this is a 2D drawing the spaces in between the chair are just as real. You should be able to draw a chair by drawing everything else but the chair:

This forces you to pay attention to the shape of the negative space, and also the contents of the negative space.

The analogy to media images is to "see" what isn't there: how is the story constructed out of what is not shown? A typical media maneuver is to show a story without showing you the media itself, because seeing it tells a different story. So as much as this looks cool and makes you feel a certain way:

it really looks like this:

Which doesn't make you feel that kind of way anymore.

You know this, but willingly unknow it to enjoy the movie. But we also willingly unknow that this same setup exists when they're interviewing the President or getting footage of a protest. The top picture doesn't just leave some things out, it leaves almost everything out except one tiny part. The top picture's focus is Indy; what is the bottom picture's focus?

Looking at the bottom picture, try drawing Indy as the product of negative space only. Did you consequently notice the guy behind the idol?

IV.

I've only covered a third of the book, but the three lessons discussed here-- drawing an inverted image, drawing a hand on a glass plate, and drawing the negative spaces are sufficient to improve your drawing immensely.

But I wanted to conduct an experiment.

pre-test

An 8 year old girl with Tourette's "copied" the cover of the Junie B. Jones book as part of a book report. Even the slug and the rabbit are unhappy about how they turned out. My experiment was: could she draw better after practicing those three exercises (inverted drawing, hand behind glass, negative spaces)?

This is the first attempt after practicing the exercises:

attempt 1

You can already see the improvement. Notably, she is trying to draw what she sees, and not relying on the default symbolic drawing that gets you slugs and rabbits. But she's not entirely free of the symbolic: the legs and arms are still spaghetti tubes that bend unnaturally; Jim's left hand is not bad but his right hand is still a childish heuristic. This happened not because arms are harder to draw than faces, but because arms are less important to her than faces and so she fell back on the symbolic.

Back to the exercises. Finally:

attempt 2

I realize this looks like the final, polished result, but it is actually only the third time the girl ever drew this picture; there were no other attempts. Note that it is all free hand pencil outline, with no mistakes (except one, behind Meanie Jim's head.) It's an amazing improvement. She is drawing what she sees.

I'd consider this experiment a success, but there is one more thing that makes it all the more significant and the real point of the experiment. If the problems of drawing are not technical skill but cognitive-- if it is truly a problem of perception and not manual dexterity or talent-- then the real work has to be done by the mind, not the hand. In other words, in order to become a better drawer, she shouldn't need to practice drawing, she needs to practice seeing.

So I made her practice the three Edwards exercises in her head. She never drew her hand using a glass pane; she stared at her posed fingers, and imagined how her pencil would move across an imaginary glass pane.

So what you are seeing is not her third attempt at drawing Junie B Jones and Meanie Jim; it is the third time she touched the pencil.

I will point out a tremendous secondary benefit to self-esteem, and now that she knows how to draw, she wants to draw, reinforcing the maxim that the best way to get a child to like doing something is to make sure they are good at doing it.

I wonder how well someone might learn any skill if they imagine practicing the skill. It might not be as good as actual practice, but how not as good is it?

1. A common misunderstanding about Freudian dream interpretation is that the dream images are explained using words, i.e. "I dreamt of a cigar, and a cigar is a symbol for penis." Dream images may be metaphors and rebuses for unconscious thoughts, but the descriptions of dreams are themselves metaphors and placeholders. Example:

"In my dream I saw Tom go over to Sally who was wearing a really bright white shirt."
What comes to mind when you think about the shirt?
"Just that it was so bright."
What comes to mind when you think of the word, "bright"?
Bright? 'Smart', I guess....

===== ====== ===== The Last Psychiatrist: How To Get Rich In Psychiatry Steps 1-5

No one ever tells you this stuff in residency. So I'm going to give you ten steps towards wealth. This isn't about being a better doctor, okay? That's what all the other posts are for. This is simply about making money.

1. Roth IRA
The Roth allows you to put away $4000 a year. It is after tax income. But anything that happens in that Roth account is never taxed. If you buy the next Google and it quintiples-- no tax. When you withdraw it, no tax.

Contrast that with regular IRAs: whatever you withdraw is taxed as income. So if you withdraw $10,000, you pay income tax on that. The logic is that when you retire and stop earning income your tax rate will be less than it is now that you work. Great. Do you know any doctors who retire? And do you believe taxes are going to go lower as the years go on?
The reason the Roth is #1 on my list is a) it is powerful; b) you must do it immediately, in residency. Once your income exceeds $100,000/yr, the rules prohibit additional contributions. You have four years. Go.
If you are an intern, you make $38,000/yr. Therefore, you can save $4000-- it should all go into the Roth. Skip meals out, moonlight, whatever. You must do this. The only reason not to put $4000 is credit card debt, which must be paid off.
You say, "I can't afford $4000 a year." False. Would you be an intern if it only paid $32,000/yr? Of course. You'd find a way. Therefore, you can save $6000/yr. All I'm asking is $4000. No buts. Just do it.
Why is it so important? Because when you save is even more important than how much you save. At 10% growth per year, money doubles every seven years. (Take 72 and divide by the interest rate, that's how many years it takes to double your money.) So if you put away $12,000 in residency, then have a kid, by the time he's ready for college you have $85,000. Tax free.
Unlike IRAs, which must be used after retirement, Roth IRAs can be passed on as gifts. So if you get rich and don't need this money, you can just give it away. It is the financial equivalent of hiding money under your mattress with a rod of plutonium and and waiting to see what happens.
Where do you get a Roth? Anywhere. All banks offer them. All brokerage houses offer them. Etrade, Vanguard, Fidelity, everybody. Also, you can invest the Roth money in anything you want. You can put it into a mutual fund, or all into Apple stock, or divide it among 90 stocks and mutual funds, etc. You can daytrade your Roth IRA money. The only thing you can't do is withdraw it before you are 59 1/2.
Sort of. Actually, you can withdraw from your Roth anytime you want-- which you will never, ever, do-- if you are going to use it for "qualified first-time homebuyer expenses." And, (unlike every other kind of IRA) you can withdraw the original contribution amount anytime, without penalty. Example: you contribute $4000. It grows to $11M. You can withdraw $4000 without penalty, because technically you already paid taxes on the income that generated the $4000. (None of this matters, because you will never, ever, withdraw that Roth money.)
2010: Something wonderful will happen
In 2010, any money you have in a regular, traditional IRA can be converted into a Roth. (Right now, anyone who makes over $100,000 can't do this.) After you convert, the money is forever immune from taxation. You can even pass it on as inheritance (a traditional IRA must be used starting at age 70.5).
I can make a prediction: you will absolutely not become rich if you do not open a Roth. The Roth is a test of self-discipline, of delaying gratification, of the ability to see the future as reality and not as potentials, fantasies. If you fail this test, it predicts you will live the rest of your life always trying to "make it," to get by. You will worry about your salary, about the mortgage, about the electric bill. You'll be doing accounting maneuvers in your head while on vacation. In short, you will become your parents.
2. Don't do a fellowship.
Every year I tell psychiatry residents not to do a fellowship, and every year no one listens to me, and every year people from previous years come and tell me they wish they had listened to me.
Unless the fellowship gives you credentialling to do something that no one else can do, it is worthless. So doing a cardiology fellowship is valuable. Doing a bipolar fellowship is not. What does a fellowship get you? Nothing. Are you telling me that a person who did a Bipolar Fellowship at Harvard is any better able to treat bipolar than someone who reads on his own and sees patients? I need an extra year of residency to learn how to use Lamictal?
Similarly, forensics, psychosomatics, pain. I do a lot of forensic work. It has never once come up, in court, with lawyers, no one, if I had done a fellowship or if I had taken the Forensics Boards. Why? Because no one wants an expert in forensics. They want an expert in psychiatry.
And patients certainly have no clue that you are or are not subspecialty certified.
But what about the knowledge, the training? Psychosomatics (consultation/liaison psychiatry) offers a good example. When you're not the person who is really responsible, you're only partly learning. Doing a fellowship in Psychosomatics may expose you to more patients (and even that's debatable) but you don't really, really learn how to handle them because you are not really, really responsible for them. You get much better "training" if you actually get hired as a consult psychiatrist. See? After a year of fellowship vs. a year of actually doing the job, who do you think is more qualified?

I know, you're thinking, "why would they hire me with no training?" Answer: because they have no choice: most places cannot get enough good people. (Are you good? If not, consider law.)
There is one thing a fellowship does get you: $50,000 less money then if you just went out and worked. Doing an Addiction Psychiatry Fellowship does not get you better training-- and gets you less experience and less money-- than simply working in a drug and alcohol program or even in a community mental health clinic.
$50,000 less for one year isn't a lot? Hmm. Assume you clear $30,000 after taxes. In 14 years, at 10%, that $30,000 is now $120,000. Congratulations: you can now take a year off and go back and do a fellowship.
3. Declare yourself an expert.
Declare: not just become, but declare.
Certainly you need to become an expert if you're going to succeed. But you also have to announce it to everyone who will listen. You need to be the person everyone reflexively thinks of when a certain situation arises. For example, if you like OCD, then as soon as possible-- in residency-- tell everyone you know you are (say this exactly) "interested in OCD." So that every time a resident or attending in any specialty meets an OCD patient, they immediately think of you.
The referrers actually have no way of telling whether you really are an expert or not; that's not the point. You simply want to create an immediate association between "OCD" and you. This way, you get all of the referrals. Most likely, they don't know anyone else to refer OCD patients to, so why not you? This is also why your expertise can't be in something common. There's no room for any more bipolar experts. But OCD, forensics, "medically unexplained physical symptoms"/somatoform disorders; use of ECT/MAOI/Clozaril; student issues; gay and lesbian issues; personality disorders, etc-- all these things are sufficiently niche but sufficiently in demand that you establish a name and thus career. You doubt this? Observe:

"Oh crap, I have another borderline patient."
"Oh yeah? Just refer them to X, he sees all borderlines."
"Really? Ok..."
It goes without saying: once you declare yourself an expert, you better fast become one. Experience AND reading. Reading all the time. I said all the time.

4. Learn Spanish or Russian. Or Chinese or Vietnamese.
If I have to explain this, it's not for you. Partial proficiency in Spanish guarantees you a 30 hr week at a salary of $150,000/yr.

5. Invest in stocks. Under no circumstances invest in pharmaceutical companies.
When doctors buy drug company stocks, it is a disaster. Doctors think they have some better knowledge of drug stocks, but their information is always flawed. Always. In fact, if a doctor tells me he is thinking of buying Pfizer, I know Pfizer is going to implode. Doctors think that because they see Geodon being used a lot that Pfizer is going to go up. Wrong, for two reasons: first, people already bet that this would happen, probably even before you knew there was a drug coming out called Geodon, so the run up has already happened. Secondly, the stock price reflects growth, not earnings. If the company made a billion dollars this year, great. But if it doesn't make more than a billion next year, the stock is dead. So Amazon, Microsoft, Intel, Dell, etc-- all great companies, all making money hand over fist-- but no significant prospects for growth. So too Big Pharma. Unless there's a great new drug in the pipeline, forget it. And by the way, if the new drug already has a name (as opposed to a numeric code) then it's too late.

If you have no stomach for this investing stuff, buy the following stocks and go back to bed: BRK.B, SHLD, GOOG, USO, COP, AAPL. (I own them all.) Call me in 20 years.

Update on these stocks here.

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===== ====== ===== The Last Psychiatrist: How To Get Rich In Psychiatry Steps 6-10
These are five more steps. This is tentative; what I plan to do is consolidate and reorganize the 10 steps into one post. But I think there is still value in this draft.

6. Get Life Insurance, a 529, and another Roth.
If you have a child, you need this.  Immediately. Shut up. I said immediately.

Term Life Insurance
e.g. "If you die within 20 years (the term), we will pay your spouse $2M. For this coverage, you will pay us a monthly premium of $300, which will rise after ten years."
Term insurance is for a set period of time.   If you live past the term, the insurance expires.   Examples are 5 year, 20 year, “until age 90,” etc. For a healthy mid thirties person who neither smokes, drinks, nor takes medication, you can get a $2M 20 year term policy for about $100-300/month. However, if you are eligible (military=USAA; medical or teachers=TIAA/CREF) you can get it for much less. Premiums increase over time.
Permanent Life Insurance (also known as whole life insurance)
"Whenever you die, no matter when you die, we will pay your spouse $2M, plus any interest that has accrued from a portion of each month's premium. For this, you will pay us a monthly premium of $800, which will never change."
Whole life insurance is forever. Additionally, after the first year, part of your premium goes into the insurance as a “cash value” on which you earn interest, all tax deferred. Think of this like buying a mutual fund within an IRA, and contributing a little every month. This is because when buying whole insurance, you are basically buying insurance AND shares in the insurance company. Certain kinds of life insurance (“Mutuals”) also pay you dividends based on surplus in the whole insurance fund.
You can also use the cash value at any time to buy a home, pay for college or your retirement. And the premiums never increase.
I favor term insurance; I need another investment that pays only 4% like I need syphilis.
529 plan: I am amazed at how many people I have to kick in the teeth over this. Assume that your kid's 4 years of college will cost you $110k. At a doctor's tax rate, you'll need to have earned $180k. A 529 plan is like an IRA, but instead of being allowed to use it for retirement, you can (only) use it for "qualified education expenses:" tuition, books, travel to the college, room, food, etc, etc. Anything at all that can be associated with education.
It doesn't have to be college. It can be medical school, vo-tech; You specify each account for a specific child; but any money that isn't used you get to keep (though those withdrawals are taxed.) Or you can transfer the money to another kid, or your kid's kids.
The advantage of the 529 is that any growth of that money is never taxed, even on withdrawal (assuming it is for education.) Following this logic, in order to save $110k for college, you only need to invest $27k at the child's birth (assume 8% growth.) Think about this.
The beauty of the 529 plan is that it is essentially a legal tax dodge. You can save much more than would ever be needed for the kid's education, tax free, and keep the money after they graduate. And the money cannot be taken in a bankruptcy. Is anyone listening to me?
Roth for Kids: Did your lazy, pot smoking, iPod wearing ("it has to be white!") MySpacer make some money from that one summer he pulled it together enough to work? Declare that money, pay his taxes (i.e. $0), and put it in a Roth in his name. Maybe your kid is an industrious 9 year old who washes cars when not at Mandarin class? Declare it, pay the taxes, and put it into a Roth. Oh my God-- if you put $4000/yr into his Roth for ten years, he will have 11 billion dollars by the time he graduates. You'd be crazy not to!

7. Open a clinic and form an LLC
If you do solo private practice, you will make a comfortable living. You will not become rich. This article is not called, "How To Rot In Your Own Self-Satisfaction."
You need a clinic: one or two psychiatrists, one or two therapists, one or two NPs (these can overlap.) It is not necessary to share the same office, but you need to be in the same building. I'd argue NPs are more valuable than psychiatrists (less knowledge at the beginning but more motivated), but that's for another day.
Refer to each other. If the patient comes only for therapy, have yearly psychiatric checkups with the MD. If one of the clinicians is an expert in something but the patient is being treated by someone else, refer for a consultation.
As I said before, your clinic should advertise as specializing in some things: Treatment Resistant Depression; OCD; Adolescents; Borderline Personality Disorder; Independent Medical Examinations (IMEs= disability evaluations; you are not the treating psychiatrist, and you get a flat fee per eval;) "treatment of impaired physicians" (a gold mine-- contact the local medical society chapters and let them know you exist); Clozaril/lithium/meds that need regular blood work. (For example, have a Clozaril Clinic: all Clozaril patients come at the same time and get their blood drawn (by the RN) and clozaril (and other meds) dispensed (by the pharmacist of your local pharmacy, who will make money on the pills)-- and you can bill each patient's insurance for the service.)   And hook up with the local schools, colleges, and area internists-- get their referrals. (The best way to do this is to go there, (unannounced or by intro through a drug rep) and meet them-- it takes 8 seconds for the deal to be solidified because why not refer to you?
This will work precisely because you are a clinic and not a solo psychiatrist . Somehow, being part of a group conveys the impression of expertise, professionalism. It's like a mini-medical society. And people refer to them.
The NPs can prescribe, and there is no reason why they cannot be as skilled (or unskilled) as any psychaitrist)-- but they can also do nursing maneuvers: EKGs (bill for them,) labs (bill for them,) and preventative screenings/counselings (diabetes, smoking, etc (bill for them-- yes, you can get money for it.))
Limited Liability Company: In the past, the only way to shield yourself from liability was to incorporate your practice, "Joe's Medical Practice, Inc." (Usually an S corporation or PC.) The corporation is a separate legal entity (that has assets, like furniture and computers; and liabilities, like you). Any lawsuits would be against the corporation, and thus your personal assets can't be taken in the settlement. If the corporation gets bankrupted, your IRAs are still safe. (But if your car is a business asset, it can be taken.) On the flip side, however, you have to pay corporate taxes on the revenue and then personal income taxes on what you take home, i.e. 30% corporate + 35% personal= death. Also, you have to have recorded meetings, bylaws, paperwork, etc.

An LLC is a company, not a corporation; no corporate taxes, no double taxation, no meetings. But, it is a seaprate legal entity, so you have liability protection.
Be careful to keep the assets separate. If you use your car for work and soccer games, it is up for grabs. If you buy groceries on the business credit card, you are destroying the distinction between you and the company.
There may be some instances where an S corporation is better for your clinic. For example, LLC members (i.e. you) have to pay Medicare and Social Security taxes on all of the business' profits. S corporation members are actually shareholders-- and get paid partly through a salary (so you have to pay Medicare and SS taxes) but partly through dividends (no Medicare/SS taxes.)
Consult your local attorney for more info, I'm just a psychiatrist.

8. Save money.
I know, this one sounds stupid because it is "easy." But no one does it. Listen to me, fools, listen to a story my Dad used to tell me, which I paraphrase here: Pretend you are a resident, and you "only" make $39k/year. Would you have taken the job if they only paid $35k/yr? Of course you would. Then you can put away $4000 per year-- in a Roth. Don't laugh-- do it. Maybe you make more than $100k? Open a Roth for your kid. Now. A Roth AND a 529.
Consolidate your loans: doing this lowers your monthly payments but extends the life of the loan (so you'd end up paying more.) However, take the money that you now save from this and fund your Roth because after you make >$100k, you can't do this. After you start making big money, you can pay off your consolidated loans as fast as you want. The point is to get extra money now that you can save in a Roth. Because the max interest rate on federal loans is 8.25%-- you can make more than this in a Roth.
Credit cards should be paid off immediately, then burned-- even GOOG can't compete with 18% interest.   And if you tell me you need credit cards to survive I am going to subpoena the bills and If I see anything from Nordstrom's, I'm going to burn your shoes.
Private Mortgage Insurance:   If you did not put down at least 20% of the appraised value of your house, you are paying an extra 0.5%-1%. For a $400k house that's an extra $150/month.   If you bought your house in the past year or two, more than likely it appraised less than you paid-- check this.   If you cannot afford to put down 20% (I should ask why you are buying such a house), pay extra principal in the early months, and get the loan down to 80%-- and then call your lender to cancel the PMI, because they won't do it automatically until 78% (snakes.)

Sell stuff: More than likely you have old technology, clothes, furniture, etc that you could sell on Ebay. But who needs that headache? i-soldit.com is a national chain of stores that sells your stuff on ebay (and charges 30%). But who cares? The sooner you sell that old cell phone, the more you'll get for it. Put this money into a Roth.

9. Connect with drug companies.
Let me introduce myself to the room, I am the large elephant.
This advice is like telling people to trade stock options. It's almost guaranteed not to work except for a handful of very savvy people; but everyone else not doing it assumes those who do are making a fortune. And there's resentment all around.

At the risk of blowing the lid off the muddled symbiosis that exists between Pharma and psychiatry, let me give you the reality.
First and foremost, Pharma does not hire shills. They simply cannot. First, shills are illegal. Secondly, all of those physician-speakers are hired not by the company, but by the rep. Pharma does not pay doctors to write scripts, for the simple reason that the people paying (the reps) would lose their jobs instantly.
Let me explain:
Doctors can get money from two sources: the corporate level and the rep level.
The corporate level: Pharma decides who are the "thought leaders" in psychiatry, and gives grants to them or their university to write review articles, give Grand Rounds or CMEs, etc.   In this way, the money is indirect. The doctor is doing something else (like giving a Grand Rounds) that has "nothing" to do with the drug company or the drug, per se. For example, right before Strattera came out, there were a billion articles written about the pharmacology of ADHD, behavioral phenotypes of ADHD, etc. Strattera was never mentioned (it hadn't come out yet), but you see the move. The doctor gets to write his "scientific article" and Pharma gets a market readied.
Corporate also gives grants to do research ("An open label study of Prozac in...")   The doctor doesn't get the money directly, it is used to pay a portion of his salary. For example, if he makes $100k/yr (yes, that's all,) and he has grants totalling $10k, he gets 10% fewer clinical duties.
Importantly, these big name psychiatrists can be very haughty, holier-than-thou, because they don't "get paid to write the drug." This is disingeuous because they don't write any drugs; they don't even see patients (except in research studies.) So they really should just shut the hell up, if that's okay with everyone.
The rep level, things are different. Reps get paid by market share growth; so they target the "high prescribers." They don't call on the thought leaders, because they don't generate any scripts. They call on local, clinic, hospital and private practice people. Reps are not allowed to pay doctors to write scripts-- they will get fired.   Here is the part of this you must understand, that no wants to: the drug company could not care less about an individual doctor's prescribing. It doesn't matter AT ALL to the drug company if an individual rep has grown his territory's market share by ten billion percent-- it is numerically insignificant relative to the liability if the rep did something sneaky.   So if they paid the doctor to do it, that rep is GONE. (Caveat: anything can happen. I'm sure there's a rep out there trading heroin for scripts. But mostly, no.)
Reps do control a speaking/education budget. Selected doctors go through a training on a set slide deck (clinical data, rates of response/side effects, etc-- slides according to FDA specifications, and there are many) and then get paid to give lunch or dinner programs to other doctors. Only clinicians can attend-- no spouses. And the speaker must use the slide deck, because it limits liability to the company because it has been okayed by the FDA. I mention this because if you think you can go up there and blather about your version of the treatment of bipolar, forget it. Slide deck or nothing. Again, the drug company doesn't care if you douse yourself with kerosene, they just don't want trouble. Slide deck or nothing.
For this, you can get anywhere from $500 (guy with considerable experience using the drug) to $2000 (academic types, clinicians who have written papers, etc.)   And there's a max per year (e.g. Glaxo=$35k, Wyeth =$50k) which almost no one ever hits. (Caveat: these are speaker honoraria, and wouldn't include grant money and other corporate payments as detailed above.)
But you have to be willing to travel. There's only so many times doctors in your area will listen to your lecture before they want to stab you in the eye. Remember, it's a set slide deck: the program is the same each time.
Here's the other important part of this you must understand: the rep doesn't care about the company-- he cares about his own market share. It doesn't matter how great a speaker you are-- if you aren't writing the drug in his territory, you are nothing to them-- unless he thinks your program would motivate other doctors to use the drug.
Every year, 1st and 2nd year residents collectively decide such speakers are drug company shills and have no respect for them or their information. And 60% of them return in their 4th year and privately ask me how to start doing it. I'll save you the trouble: either write some papers or otherwise develop a specialty; and prescribe the drug.   If you like Risperdal and use it a lot, and hate Zyprexa and don't use it, the Risperdal rep will eventually ask you to speak. That's easy. Here's the tricky part: the Zyprexa rep IS NOT going to say, "if you write Zyprexa I'll let you speak for us" because they have a limited budget and you are simply not worth the risk. First, they don't know if you will ever use Zypexa; second, they don't know if your Zyprexa progam will be good enough to convince other doctors to write Zyprexa; and if you are good, then the Risperdal rep has already come to you-- and no rep will use you if you already speak for someone else because you won't be believable to the audience and thus will be useless to the rep. This part is hard for people to understand; they think that "the drug company" wants to "pay doctors to write the drug," and reps thus contribute to company profits.   The reps are individuals; they compete against each other in their own company. In fact, they'd rather no one prescribe the drug except their own doctors. Their budget goes towards building their market share; but again, no nonsense, the company doesn't want the risk.
This is sales, not a cabal. The reps are interested in exceeding their quota and making a bonus; not in global hegemony.
So being a thought leader can get you pretty good money (which is helpful as academia pays nothing.) But being an ordinary speaker will not make you rich. But it does give you a not insignificant amount of money you didn't have before-- which, if you have any brains in your head at all, you will put in your 529 or ROTH and buy COP, BRK, GOOG, etc. (And I like ATI. (I own all of these.))

10. Write a blog; ask for donations.
Ok, maybe not rich. But every little bit helps.

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===== ====== ===== The Last Psychiatrist: How To Get Rich In Psychiatry (update on stocks)

Hi. On 9/25 I recommended 5 stocks. Here's where we stand one month later:

BRK.B    3123   3333 +210 (7%)
SHLD     160   180    +20   (13%)
GOOG    404     480 +76   (19%)
USO        56      52   -4   (-7%)
COP        57      61   +4   (7%)
AAPL       76      81   +5   (7%)

For comparison, the S&P rose 4% during this month.
So there you go. And, for the record, I now own only GOOG and BRK. USO should continue to fall (and so should consequently, COP) until either it gets really, really cold outside, or until April (it is cyclical, after all.) But when USO goes up, GOOG should go down.
And USO is a winning play over the next decade. I can only be sure of that with SHLD and BRK.
In case anyone cares at all, I also own AKAM; I'll be buying back AAPL this week; and I'm looking at ATI.   These should be solid plays until Christmas, though I'm expecting some sort of massive retracement this week.

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===== ====== ===== The Last Psychiatrist: How To Lose Weight, Method #394
P.S. If you can't tell, this has only very little to do with losing weight.

Strategy: after every single meal or snack-- anything at all-- floss and then brush your teeth. Both.

Why it works: Self discipline often fails because it is counter to your impulses. Telling yourself not to eat that snack is pitting what you want now against a different thing you want for incomparable reasons that occurs later on. Good luck.

A better strategy is to exert self-discipline over something with no real opposition, a positive action. It takes much less self-discipline to force yourself to do something you don't want to do (e.g. flossing), then it does to not do something you want. (Furthermore, flossing and brushing, while not fun, have a reward in their completion.)

It's 9pm. You've already flossed and brushed after dinner, and now you see a cookie. You could easily eat that cookie, but... ahh, forget it.

Make it part of your life: after any food, floss and brush. Make the feeling of unbrushed teeth be unusual, uncomfortable-- not you.

Don't try to stop being something (a snacker); try to start being something else (a person who flosses and brushes a lot.)

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===== ====== ===== The Last Psychiatrist: How To Promote Energy Conservation

won't help

1. "A 2000 W dishwasher typically uses 2000 units of energy in one hour. How many units of energy do you think each of the following devices typically uses in one hour?"

central air conditioner
electric clothes dryer
laptop computer

Repeat your answers so you don't change them later.

2. "How many units of energy would each of the following changes save?"

Drying clothes on a line for one load (i.e. not using the dryer for one load)
Changing washer temperature from hot wash/warm rinse to warm wash/cold rinse for one load
In the winter, turning down the thermostat (make home colder) by 5 degrees

Repeat your answers so you don't change them later.

II.

Please forgive the odd phrasing: I copied it exactly from the survey. The study, Public Perceptions of Energy Consumption and Savings, in PNAS, asks two questions. The first is, "what are the public's perceptions?" The second is, "why do they have these perceptions?"

Here are the results of the study of 500 people:

Ignore the X-axis, look at only the y-axis, "Perception." As you can see, the perception was that most objects used about 300Wh (between 100 and 600.)

Look at your answers, above. My guess is your guesses were in the 1000+ Wh range, which if true is important because:

There is a 5-10x difference between you and the people surveyed
You were more accurate

So what accounts for this? Run the possibilities. Are you smarter? Are they idiots?

II.

The anchor: I told you about a 2000W dishwasher; the original survey said:

A 100W light bulb uses 100 units of energy in one hour. How many units of energy do you think each of the following devices typically uses in one hour?

One clue that you're in the presence of anchoring bias is when lots of people get the answer wrong in the same direction by the same amount. As in the graph below, nearly all appliances were underestimated-- because they were sucked towards a 100W bulb as an anchor.

Additionally, they had more appliances to rate, which themselves form anchors. The gravitational pull of stereo, laptop, and light bulb overwhelm the unknown quantities of dishwasher.

If you wanted people to guess more accurately, you could try to teach them about each machine; but its probably easier to simply give them one better, larger, anchor.

II.

The anchoring bias is everywhere, described formally in 1974 by Tversky. This was his example: Guess the answer in 5 seconds:

8 x 7 x 6 x 5 x 4 x 3 x 2 x1 = ?

vs.

1 x 2 x 3 x 4 x 5 x 6 x 7 x 8 = ?

The median guess was 2250 for the first descending sequence, and 512 for the ascending-- half the people guessed a number smaller than this. The answer is 40320.

Neither does the anchor need to have anything to do with the question. Tversky describes asking subjects the percentage of African countries in the UN, but first they watched a wheel randomly pick a number. For the groups that saw the wheel pick 10, their median guess was 25. For those who saw the wheel pick 65, their median guess was 45.

III.

The main problem with promoting energy efficiency or energy use reduction is that these are solutions to a problem most people do not feel they actually have. "Meh. I try to turn off the lights, but it doesn't seem to affect my bill."

Secondarily, energy conservation is presented as an ethical problem. I probably don't need to explain why this fails.

All social policies-- the most rigorously considered to ill-conceived-- are ultimately dispatched by marketing.

In any new product launch, a market is served or a market is created, but in either case the appeal is to the individual, not the market. You can argue that Lilly created the market for antidepressants or it served an existing market. Either way, the success of Prozac was due to it appealing to each individual user of Prozac. Not: "Come on America, you all need Prozac!" but "you, woman in her mid thirties feeling lost and depleted, need Prozac."

Energy efficiency/conservation fails as a marketing strategy, because it appeals to all of us as a society. We hate that. "What's in it for me?" Well, I'm glad you asked...

But follow the analogy to the end: when Pharma sells the drugs, the customer is the doctor, not the patient. The patient can't really affect the market because they don't really know the alternatives.   "Oh, I should take Prozac? Ok. Should I be buying Blu-ray or HD-DVD? I heard HD-DVD is better?"

Ultimately, a society can't possibly conserve as much as a more efficient machines can save.

The prescribers of energy consumption are the companies that make the products, and Pharma is the government. If you want GE and GM to make energy efficient products, you have to incentivize them to do so.

In the end, we'll buy whatever the ads tell us to buy.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: How To Take Ritalin Correctly
This is a post about Ritalin, Adderall, Dexedrine, and others-- it is meant for those for whom it is written. You know who you are.

I've written three textbook chapters and a couple of articles on stimulants, and I may or may not have taken them at one time or another, so I'm an expert.
Because I work in a university hospital, and because I'm, well, different, I get approached by college or med students at least once a week for Ritalin or amphetamine prescriptions. Every one claims to have "ADD." (NB: I don't give them out.)
They want the Ritalin to help them study. I get it. I'm not advocating it, but if you are going to use Ritalin you should probably do it intelligently, to maximize the gains.
First, a disclaimer: you should only get Ritalin for indicated disorders by prescription from a physician. Ok? Because the doctor will rigorously apply artificial and unreliable diagnostic categories backed up by invalid and arbitrary screens and queries to make a diagnosis. So after this completely subjective and near useless evaluation is completed, your doctor should be able to exercise prudent clinical judgment to decide if Ritalin could be of benefit. In other words, he will ultimately decide based on little else but his own prejudices and/or consult the Magic 8 Ball. That'll be $250, please. Cash appreciated.
That said, the key to amphetamines and Ritalin is to stop thinking of them as stimulants, and to think of them as reinforcers.
Let's conceptualize how these drugs work. Imagine getting a brain scan while you are performing a task. The parts of your brain you are using for the task will light up, brighter than those you aren't using.
Now you drink coffee (1). The whole brain lights up brighter, proportionally.

Now you take amphetamines. The parts of your brain that you are using light up brighter, but the parts you aren't using go darker. Get it? Caffeine is a global brain stimulant, while amphetamines focus your attention, reducing distraction.
This is entirely selective and controlled by you. You have to decide what you want to focus your attention on. If it's reading, the reading parts of your brain will be brighter. But if you stop reading and decide to talk to your friend on the phone, you know, the hot one with the hotter roommate, then you'll be more focused on that (obviously). Attention is always decreased when it is split among several tasks. In other words, you can only concentrate on one thing at a time, even though it may feel like you are doing two things at once.
While amphetamines and Ritalin do stimulate you and keep you awake, using them to pull an all nighter completely subverts their awesome power. If you want a stimulant, drink coffee or Red Bull. Amphetamines should be saved for reinforcement.
You want to set up a study situation that as closely as possible resembles your testing context. Do you take tests in the middle of the night? Using multicolored highlighters? With The Daily Show on in the background and eating Doritos? Then you're a pig, and you deserve to fail. You're dead to me.
You should study in the morning, at a desk, under the same "fed" conditions as on test day. (So you would have eaten before taking the test, not snacking at the test.) Quiet room, no distractions. Remember, attention is decreased with multiple stimuli in normal conditions, but on amphetamines, this will be be greatly magnified. Studying while talking to your friend means your "talking to friend" parts of the brain are brighter while your ""studying" parts of the brain are darker. Same thing with listening to music and studying.

Take the amphetamine (takes about 30 minutes to "kick in.") Study, straight, with no distractions or interruptions, for about four hours. Quit. You're done. Amphetamines give you about 4 hours tops of great concentration. Go to lunch, the gym, watch a movie, etc.
The power of amphetamines is this: you take them again, in the same dose, 30 minutes before your test.
In a metaphoric sense, taking the amphetamines during the test, under the same circumstances as you had been previously studying, will "remind" the brain of that context. If you see a question that "resembles" something you studied, your mind will be primed to recall it better.
Remember I said you can only concentrate on one thing at a time, that attention decreases when it is split? The trick here is to make everything about studying into one large "thing."
Here's an example: if you listen to a symphony, you will hear music. Musicians, however, hear both the music and every single instrument. They can attend to each instrument individually and simultaneously hear how each instrument fits into the larger context. A non-musician can't do that. If he's concentrating on the oboe, he doesn't "hear" the violas.
Studying has to become a large symphony, everything doing its part correctly, expectedly. So on performance day (testing) you play the same symphony. You're not trying to concentrate on each part, if you've practiced enough it should be second nature. The amphetamine helps facilitate this.
Addicts can get physical feelings of withdrawal or "high" simply by being presented with the cues-- the environment-- of their drug use. And they key into these cues much faster than non-drug related cues. That's what you're looking for here. The amphetamine feeling "reminds" you of what you studied.
For example, what you don't want to do is NOT take amphetamines at testing if you had used them to study; or take them at testing if you didn't use them to study. Or change the dosage, or change anything else you eat. (2)
Similarly, you should only be taking one pill a day. Don't take amphetamines to study AND later to do other things (like go out at night.) You are destroying the context specific reinforcement. Additionally, tolerance to amphetamines happens pretty quickly-- if you take them every day, you're going to need higher doses as time goes on. Ideally, you'd use them only for the last stretch of time before the test. For example, maybe you'd take them only the last week or so before the test, when you are studying from back tests as opposed to a textbook. (See the context?) And you'd stop using them after the test, give yourself a break, etc.
As a public service announcement, don't worry too much about grades. This is America, not Germany, where success is determined by the solidity of your goal and the amount you are willing to work. I know you don't believe it now, but it's true. Go have a drink.

IF YOU LIKE IT, DIGG IT AND MAKE A DONATION
and hey, what gives with the trilogy The Most Important Article on Psychiatry You Will Ever Read? It's funny, dammit, so digg it!
---
1. What is the best and healthiest coffee to drink?

2. NB: diet and amphetamines are powerfully interactive. Acidic foods/beverages will rapidly accelarate the clearance of amphetamines. In other words, dexedrine + orange juice = a lot less dexedrine. (BTW, does anyone have any idea how to make footnotes with Moveable Type?)

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===== ====== ===== The Last Psychiatrist: How To Treat Vertigo
In Neurology, found by way of Women's Health magazine October 2008, and no I'm not ashamed to admit it.

Vertigo can have numerous causes, so that's unfortunate.

One type, benign paroxysmal positional vertigo, is characterized by brief episodes triggered by changes in head position vs. gravity in the absence of other causes. E.g. lying down.

In this test, the doctor (the older man with the white hair, obviously) is testing the right side: he turns the patient's head 45 degrees to the right, and then quickly lays her down. Nystagmus occurs; you have veritgo!

What is happening?

God decided to make those canals be orthogonal-- the horizontal canal laying horizontally, and the other two vertically separated by 90 degrees. They are filled with fluid, which swish around as you move. In essence, the swishing is what the brain reinterprets as movement.

Little calcium carbonate crystals (otoliths) dislodge from the utricle and fall into the posterior canal. Now you have a little rock in your fluid filled tube, which causes all sorts of swishing on its own. Now you have vertigo.

Gravity is the key. Since the posterior canal is the most likely place for the crystal to go, and the posterior canal is mostly upright, the biggest effect of the swishing crystal will be when you lie down (and it is free to move.)

What do you do about it?

Practice.

There are several maneuvers used to literally roll the crystal out of the semicircular canal. Here's one:

Steps in and 2 are just like the test.
Step 3: turn the head 90 degress to the unaffected side, and hold for 30 seconds
Step 4: then turn the head (and body) another 90 degrees so the head is face down (not well depicted in this drawing)- hold for 30 seconds
Step 5: sit up.

One study found the awesomeness of this maneuver to be 88% vs. sham maneuver 26% one month after treatment. Not bad for no meds.

Keep in mind the body position is irrelevant, what matters is accurate head positioning. The crystals are very sensitive to the force of gravity, so the more accurately you can move the head, the better. NB: this maneuver is will cause the very veritgo you're trying to treat, so bring a bucket.

===== ====== ===== The Last Psychiatrist: How To Write A College Application Essay Or Personal Statement

Sometimes you know something but the full significance never makes it to consciousness, because your very soul rebels against the implications: we've been doing it wrong all this time?

NYMag: You've Got Mail: Inside a top college's admissions room. That college is Sarah Lawrence. Ring a bell? Some of you silly people will remember that Blair on Gossip Girl got rejected from there, but anyone over 30 will no doubt remember The Simpsons:

Mr. Thai [Thai restaurant owner] to Bart: Put flyers on doorknobs. Then I get more business. Send daughters to small liberal arts college. Swarthmore. Maybe Sarah Lawrence. Call professors by first name. Dynamite!

Bart later tosses them in the dumpster, and when the restaurant owner finds out:

Mr. Thai: You a quitta! Quitta boy! Now restaurant fail. Children go to state college. Serious students powerless against drunken jockocracy. Baseball hats everywhere.

Sarah Lawrence evaluates a student's performance in three spheres: academics, writing, and "personal", defined as extracurriculars and "other background." I'll leave the merits of "other background" to The Weekly Standard. The issue for us here is the college essay.

Read this:

Standardized tests are supposed to correct for the ways high-school grading systems vary, so to make up for that, Sarah Lawrence's committee uses a sample essay graded by a high-school teacher to determine the curriculum's rigor. But the samples also tell something about the readers. "I had one essay that said how awful Twilight was"--the essay was about damaging themes of female submissiveness in the series--"and I was like, 'Admit her!' " says Melissa Faulner, a 2006 grad on the committee. Whereas what the readers wryly call TCML essays--"theater changed my life"--are looked at more skeptically.

No doubt, NO DOUBT, critics of higher education and multiculturalism will jump on the implication that the committee leans left, way left, and will favor those applicants with similar predilections. WRONGINGONTHEFLOORLAUGHINGMYASSOFF. Read it again, you've missed something crucial.

'Admit her!' " says Melissa Faulner, a 2006 grad on the committee.
Still don't see it? There's a very good chance that the only person who will ever read your college essay is 25 years old.

II.

In every college admissions website, they are referred to as "Admissions Officers." While I didn't assume they were in the military, I suppose I did assume they were... old. er.

And some are, I guess, there's got to be an Admissions Dean in the building somewhere. But the average applicant is writing an essay that he thinks an adult with a suit and three kids would want to read. Instead, it's probably being read by someone who can't wait for the new iphone and still bites their nails. Ten grand says they think Jon Stewart is "a freakin' political genius."

But surely there are some adults on the committee? The article focuses on Tom Marlitt, director of West Coast Admissions. They don't give his age, they give a physical description. Media-- and The New Yorker is probably the wost offender of this--   offers a physical description of their subject as a code about their character in exactly the way the media would never allow a regular person to do. If they profiled me it woudl start, "Wearing a disheveled undershirt clutching a rock..." and leave it to you to make an objective assessment (="drunkard, likely unbalanced.")   What they say about Marlitt is: "a spiky-haired man in all beige." That's media code 50 year old acting like a 25 year old.

Look, nobody likes 25 year olds more than me, especially ones that are too pretty to get into Sarah Lawrence. And there's little sense in arguing the merits of college admissions being determined by a 25 year old vs. a 50 year old when the whole college game is a carny act that works only because we agree to pretend it does, runs FIFO, and is subsidized by the government. It is what it is.

But if 85% of the applicants have already been weeded out before it gets to the committee, and they have been weeded out by a 25 year old, or a 50 year old who thinks he's a 25 year old, it would make more sense to write an essay for a 25 year old. Not for a 50 year old, which is what most people do, employing the maxim, "What essay would make my Dad happy?"   So you get: quote from some uncontroversial famous person; affirmation of one's heritage/parents; generic sycophantic praise of the school; vague promises of changing the world.

Admit him!

Before you write your essay, profile your Admissions committee members. They, not "the school", are the ones accepting you, and writing an essay for a theoretical "Admissions Officer" is like having sex with a theoretical "vagina." Yes, it means you'll be submitting different essays to different places, but this kind of information may save you from describing how much you admire Kissinger's foreign policy:

If you're targeting a(n actual) 25 year old, i.e. someone who through no fault of their own has been conditioned to prefer brevity, appeals to emotion, and branding, here are the words you want to include in your essay: "sex" (as self-expression, not conquest), individuality, curiosity, hypocrisy, naked. 25 year olds have hypertrophied BS detectors, so nothing contrived. Bonus if you can include some dialogue in your essay, everyone loves a supporting cast. Triple points if it can be read ironically, or if it is funny, especially in a self-deprecating way.

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===== ====== ===== The Last Psychiatrist: How to Write A Suicide Note

I'll write this for the ER psychiatrist seeing acute cases, but the strategy applies to all types of psychiatry. Always keep in mind what is the purpose of the note, and who will actually be reading it.

1. Write so the reader doesn't have to guess what you were thinking.
The overall biggest mistake in medical note writing is spending too much time/too many words on the "Objective" or narrative portion of the note, and not enough on the "Assessement."
Who is going to read this note? Insurance companies read the objective and bill based on it. But no one else will care about this. The only part that other doctors, lawyers, and juries care about is the assessment and plan (assuming its more than two lines.)
And so you must write your assessment and plan in a way that makes it completely obvious why you did what you did.
For example, a common error is trying to convince the reader that the person was not suicidal by listing occurrences or patient statements.   "Patient was denying suicidal ideations...had good affect and was joking with staff... etc etc." You are forcing the reader to make an inference, to have to connect the dots himself. This is bad, because what if they come up with a different conclusion? Make the train of thought obvious. "I was able to conclude that he wasn't suicidal because not only was he denying suicidality, but his good affect and joking with staff indicated to me he felt better."
Did the person shave himself this morning, with attention to detail? If yes, that's a good clue he wants to live. But write it down in the note. Don't write it as, "Appearance: clean" because it's more important than that. Put it in sentence form in the body of the note. Here's an example of a suicidal surgical patient I was saw in consultation. "I noted that he was cleanly shaved with attention to the margins along his goatee; I asked him if he had done it (or a nurse) and he said he did it, he was trying to look good." That's gold.   He may be suicidal, but he was hopeful enough to want to look good. Now link it explicitly: "This supported my assessment that he was still interested in life, and that he wanted to live."
2. Prime real estate should be valued.
The maxim "if it wasn't written, it wasn't done" is idiotic, and false. But if it is written, it shows it carried more importance to you relative to other parts of the note. Writing about a patient's future plans in the objective shows it mattered more to you than did, say, checking a box near "Appearance: Clean." Or, the reverse: not writing about his future plans makes it look like it mattered LESS to you than his appearance.
Don't waste space with SIGECAPS and the like; no one cares. I know this contradicts everything you've been taught, but it's true. It's important in making the diagnosis of depression, but the actual readers of the note (other doctors, lawyers, and juries) only care what your diagnosis was, and what you did about it.
3. Your note should be timeless.
Certainly you need to assess suicidality, and explain why you think he isn't right now. But keep in mind that your assessment will last more than 24 hours. If he kills himself next week, lawyers are still going to come looking for you-- and documenting that he wasn't suicidal at that precise instant isn't necessarily going to be enough. You need to evaluate his future and what should be done about it. For example, you have a person who has had multiple suicide attempts (but is not malingering) in the ER. You're convinced he's not suicidal now. But what about next week?
"Currently he is not suicidal, feels fairly hopeful about the future and has made some specific future plans like XXX..." [list them!]

Note that hopelessness/pessimism about future-- not depression, psychosis, etc,-- is the best predictor of suicide. So note it explicitly.
Okay, in the near term he is not likely to be suicidal. Or is he? He's had nine attempts before, after all. What about that?
"...However, given his history of [impulsiveness/poor judgment/poor frustration tolerance/drugs], it is probable that he will attempt suicide again at some point in his life. Unfortunately, this is a function of his future acute stressors-- over which I have no current control-- not how he feels right now. He feels fine now, but on the drive home something bad could happen (e.g. girlfriend leaves him, loses his job, etc) which will activate his suicidal impulses..."
That's key, because it sets up the problem: he is going to attempt it again-- let's just get that out into the open-- but that has nothing to do with how he feels today. And it explains how you can't be held responsible now for it then. So now you explain why you didn't do the "obvious" thing, which is hospitalize:

Hospitalization and/or medication now is not going to alter that future eventuality, and thus are not indicated today. In fact, hospitalization may be detrimental because it sets up a pattern of dependency. Rather than finding better ways to deal with distress, he learns to run to the hospital whenever he is faced with frustration. He does not learn how to cope with stress. The main risk is thus that if he can't get to an ER, or the distress is particularly severe, he will not be able to cope and will have an even greater risk of suicide. In essence, hospitalizing him now puts him at greater risk for suicide later..."

But what makes you a good doctor (and saves you from the charge of negligence) is the next two sentences:

"Given the chronicity of his suicidality, I have to do something that will actually help him long-term.   I believe he is not suicidal now, so my responsibility is to help decrease his suicide risk, as best I can, forever. The best way to help him is to refer him for [intensive therapy/day program/psychiatric visit, etc] for long term follow-up, so that he can have somewhere to go and someone to manage him as symptoms and stressors develop. This is the best way to keep him alive. So, we discussed a crisis plan for future suicidality: at the first sign of distress he will call X; if this is not sufficient he will Y, then Z; ultimately he will come to ER..."

That's what the note should say, in your own style and with the contents of your interview. So that when the lawyer asks, "why the hell didn't you hospitalize him?" he and the jury already know the answer.
4. The note is a not a newspaper article, it is an op-ed.
Also note the way I wrote my sentences. They are personal and informal. "Best way to keep him alive." "...over which I have no control." Etc. The note is your educated opinion, not a scientific article. You have to explain-- pretend it is to a jury, if that will help-- not just what you did, but why you did it-- and why not something else. "His affect changed when I left the room and he was noted to be joking" does not powerfully (enough) convey what you saw and what it meant to you. "With me, he was crying, but when I left the room and he thought the evaluation was over, I watched him joking and laughing with one of the nursing assistants." See how that changes things?
5. You can be wrong, but you cannot be negligent.
It should be obvious from the note exactly what you were thinking-- and, importantly, that you were thinking.   That you took time to ask questions, observe, assess, draw conclusions that were reasonable. You might have been wrong, but you did a thorough job. That's why the assessment matters. Simply having volume to the Assessment shows that you gave due consideration to the case.
In other words: the note isn't written to help you win a lawsuit, it's to prevent one from being filed. You want a potential plaintiff's attorney to look at your notes and say, "forget it, it's not worth it-- it's obvious he isn't negligent."
6. Call someone.
Very important: get someone else's opinion, and document it. It's one thing for you to say he is not suicidal; but it's tremendously helpful to have a family member tell you he isn't, or that this situation is common, or that this happens whenever he gets upset, etc. If his girlfriend, etc, seems to think it is ok for him to come home, write that down!
"Spoke with his wife, who expressed no reluctance in taking him home despite everything he had been saying."
or, better:
"Spoke with his wife who was happy to take him home, and did not think he needed to be hospitalized."

See how telling that sentence is? Sure, by itself it is meaningless, and the wife is no psychiatrist, etc. But in combination with the other things you (will) write, it details what's going on and why you did what you did.
(In the converse, you should be hesitant to go against a family member, because they know them better than you. If the mom says he needs inpatient, you have to have a really good set of reasons why he doesn't. If you can't convince mom, you'll never be able to convince a jury after they die.)
If family and friends are not available (document that you tried-- that also shows effort and is above standard of care!) then get a second doctor, or nurse. I don't mean atttending phone back-up, which is useless. I mean another resident, or an ER doc, anyone, so that you can write this next sentence:
"Discussed the situation with X who also evaluated the patient, and X agreed with me that..."
Apart from giving you a valuable second opinion, it also helps establish "standard of care," loosely defined as how a "respectable minority" of docs in your situation would have proceeded. Two docs is pretty much a respectable minority, as far as I'm concerned (and have testified to such.)

7. If you discharge a suicidal patient, you must show that this is a better treatment than admssion.
You read all this and say, "well what if they say they're still suicidal?" Let's assume they are not malingering. (I'll get to that later.) And let us assume you don't actually think they need hospitalization and should be better served somehow else.
What's the key? To explain to the reader why you kicked them out of the ER despite actually believing their suicidality. (I say "kicked out" because that's how the lawyers are going to phrase it.)
First thing is to explain why you felt he would be alive next week despite his suicidality now. What's keeping him alive for later until Thursday, when is he has his outpatient appointment?   Explicitly list all the reasons for hope for the future and his future plans.
Second thing is to explain why hospitalizing him isn't going to help him. Essentially, it's the same note as in #3.
"Given his history of multiple suicide attempts, what needs to be done is to get him through this acute situation, and then prepare him for the future. Hospitalizing him will have no impact on his future suicidaliity as it is stressor dependent.   Obviously, his history of other hospitalizations, medications, and ER visits have done little to prevent him from being at this point again and in this ER now. Thus, hospitalizing him will only "ensure" his safety for the few days he is inpatient, and do nothing to keep him alive long term. It delays, not treats his suicidality, and when another stressor comes this hospitalization will have done nothing to help keep him alive.

Given this, the best way to help him is to refer him for... [as above].

As for his suicidality now, the plan is to let him decompress and reorganize for an hour or two here in the ER. We will give him some Ativan (etc) to help him. I'll give him supportive therapy as well as try to give him some better coping techniques for the future, and have RN do the same, to reinforce it. I was upfront with my opinion that hospitalization was not helpful here, and I explained my reasons, and while he was not happy with this and did not agree--he wanted to be inpatient-- he at least understood my perspective and was satisfied I was trying to help him. Of course [note word choice "of course"], I called his family/friend/etc who agreed to come pick him up and stay with him continuously, and would not let him out of their sight, and would bring him back if things worsened, etc. I told them how and when to give ativan. etc.
This is tricky, so let me be clear: this note isn't to convince you he's not going to die. You have to already be convinced, for yourself, that despite his suicidality he will be alive tomorrow. Then, and only then, should you be writing a note supporting your decision.
8. Plan should match Assessment; You can be wrong, but not negligent.
This again? Here I refer specifically to diagnosis and plan. If the diagnosis is malingering, and you kick him out of the ER, don't write "Psychosis NOS; Plan: discharge." Because the plan is not obvious for the diagnosis. The diagnosis should be, "Malingering; Plan: discharge." Because that fits. To the reader, it's obvious.
You may be wrong. You need to work on not being wrong. But for the purposes of negligence, an incorrect diagnosis with a reasonable plan for that diagnosis is better than the correct diagnosis with an unreasonable plan.
The note should convey an obvious train of thought. Obvious means that the person could guess what your plan will be based on the diagnosis, and vise versa. A person comes in suicidal because they broke up with their boyfriend yesterday should not have a note that says, "Depression: discharge." It should say, "Adjustment disorder: discharge." Because that plan seems more obvious for that diagnosis to a reader.
If you diagnose "depression" you are implying a longstanding problem that may exist in the absence of actual stressors. You might not want to be implying this, but it does. All you meant was that the guy was sad, but now you have to write a more detailed note explaining the future course or treatment.
This applies to personality disorder. If a borderline has another self-cutting event, the diagnosis is not depression; it's borderline. Writing, "Axis I: Depression; Axis II: Borderline" means, "oh my God, she was acutely depressed on top of an underlying borderline personality disorder!" Which is worse.
9. Write the note as if the patient died, but you have a chance to change your note.
First, an amusing anecdote about why doctors are idiots. I did a malpractice case where the doctor received a subpoena for records, and sent them in. Great. Except the plaintiff's attorney already had a copy of the records, which he used to show that doctor had altered his copy after receiving the subpoena.   Game over. You lose. I am told this is a common maneuver.
So don't change your note. But imagine the patient kills himself-- and you have the ability to change your note. What would you change? If the guy shot himself, maybe you'll have wanted to write he had denied having a gun, or that you discussed removing the gun with the family. Or if he was on drugs, you'll have wanted to document discussing abstinence, protecting against withdrawal, or at least noted there were no signs of intoxication. Etc. Well, write this all in the note now. Pretend they're dead, and write the note from that perspective, in other words justifying how you could not have predicted this-- any reasonable person would have concluded they would live, not die-- and how extensively you attempted to prevent it.
And this is purusant to #2. If the patient suicided, your magnificent documentation of SIGECAPS and his Family Psychiatric History isn't going to be worth squat. It may even hurt you without a rigorous Assessment (#3). This is a real quote: "Doc, you've documented pretty clearly the guy was depressed: low energy, poor appetite, poor sleep, lack of pleasure, lack of interest in sex, chronic lower back pain-- how the hell could you let this guy out of the ER? Did it not occur to you he was going to hang himself? Or did you think he was just going to catch a movie to cheer himself up?"
Obviously, you're not supposed to lie in the note. I'm trying to get you to think proactively, to start asking the right questions (SIGECAPS is the wrong question) and assessing the right things. And then documenting them.

Write what you will someday desperately wish you would have written. Make the Assessment and Plan strong.

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===== ====== ===== The Last Psychiatrist: Hunger Games Catching Fire: Badass Body Count

sorry old man, I have a dress fitting to go to

Number of people killed: 15
Number of people Katniss kills: 1
Number of times she is saved by someone else: 6
Number of times she saves someone else: 0

But boy oh boy, wasn't she spectacular at practice, 9 targets in 30 seconds, and then she strings up a mannequin. Take a bow. Badass.

I.

For context, here is why THG is a sexist fairy tale. It anticipates most of the criticisms.

Except one. An insightful, even optimistic retort is that at least she's not killing, at least she's made the ethical choice to not kill anyone.

But this insight is exactly what you are supposed to think, it is an illusion, and it is why my tally above is also a lie. She kills one person, but she is responsible for all of their deaths. From the very beginning of the Game it was immediately true that everyone but one got killed. From the very beginning, before anyone dies, you are guilty of everyone's death.

That's the Game. It's not like they went in there thinking, "I'm not going to kill anyone because I am planning to escape this Game." No one backed up their pacifism with suicide.   Katniss's thinking is basically, "I'm not butcher, but I am going to try and survive."    The movie elevates her passivity into a moral act, which it isn't, that's the trick. This is a closed system. Whether she shoots them down herself or waits for the psychopath in the group to do it for her, it's the same.

What's important is that this "choice" not to kill, and the personal feeling of morality it (falsely) gives you is how the system survives. Because you feel good about your choice, "at least I'm a good person," you fight the system much less. You are less of a threat to the system because you are allowed to believe you're a good person and they're not. But you're not. You killed 15 people. I counted them.

The true criticism of the movie isn't that it is too violent, but that it is not violent enough-- it is Disney violence, and whenever you see the word Disney you should instead see "100% in the service of the existing social structure." The movie presents "not murdering anyone" as if it were a moral option, as if it were true; so that you are not revolted by the fact that you did kill 15 people; so that you do not fight to change the system that forces you to kill 15 people.

Just because the system tells you, "the other tributes are your enemy," doesn't mean it's a factual statement, you have to answer the Thin Red Line question: "who's doing this? Who's killing us?"

The Game is rigged to prevent all choice but allow the illusion of choice. There are Good Samaritan laws in place which protect you from liability if you give someone CPR in good faith but inadvertently crack a rib. But this is nonsense. The person motivated to offer CPR NEVER thinks about a future lawsuit, he just acts; or, in the reverse, the person who is nervous about lawsuits was never going to help anyway, and thank goodness he can blame it on lawyers. These laws have the perverse effect of allowing the us passive aggressive techonauts to observe events rather than intervene in events. "Come on, what am I going to do, you know the litigious world we live in, besides, we have paramedics for that." So you're telling me that, i.e. for example, my child got hit by a car on the street and instead of Airway-Breathing-Circulation your plan was to shift to Landscape mode? "Well..." You better burn off your fingerprints and move to Siberia.

There's going to be some who will respond with the obvious: "yes, but the fact is, not killing is better than killing-- or do you think putting a gun to someone's head is really the exact same as not doing that?" And some will counter-retort that it's like war, if you send soldiers to fight you are responsible for their killings.   Both arguments miss the point completely: NOT killing is better FOR HER, because then SHE doesn't have to feel any guilt. But everyone dies ANYWAY. Not killing is entirely a selfish act, not a moral one, if my kid gets hit by a bus the driver at least did it by accident, you CHOSE to not help, you are WORSE, see also Steubenville. "But they did the rape!" But they did it for you to see, do you not get it?

It looks like Katniss is free to make personal decisions, but no matter what her free brain decides, everyone around her dies as planned, huh, that's odd. The only "free" choice, the only way to beat the Game, is not to play. If you really wanted to be a moral agent in such a terrible environment, you'd have to convince the other tributes to all agree not to fight each other, knowing full well that the soldiers will therefore come-- that is the point of the maneuver, to expose the evil of the system instead of allowing them their deniability, "oh, we don't kill anyone, the kids kill each other!" You have to sit there and Prisoner's Dilemna the hell out of this and hope none of the other tributes breaks ranks and opens fire. It is the only anti-system choice short of revolution.

The response that this maneuver puts the individual Districts in danger, too, is, unfortunately, part of the deal. The genius of the system is that it never puts everyone at risk, it presents them with a lie: only these Tributes are at risk. If the Districts themselves don't want blowback, "we don't want trouble", if they "want" to maintain the status quo, they have to send people to participate. You don't send a Theseus, you send a Katniss, which they did, hence another round of Hunger Games. She'll look heroic, she'll perform badassly, and nothing will change, which it didn't, which is why even though she won the first movie there was a second movie.

There's going to be some of you who will be confused, "are you saying Suzanne Collins planned this? No way! You've totally misinterpreted--" No, no. Collins wrote the story, yet she is not aware herself of what she wrote; she couldn't have written the story any other way than from a narcissistic perspective because that's all she knows living in this world; or, to reverse it, had she known, had she written a different kind of story with a different kind of hero, it would never have been published, let alone made into movies, we'd be on Twilight 7.

It's here that I should SPOIL that the revolutionaries who do finally fight the system DON'T EVEN TELL HER ABOUT IT.   Everyone around her is extraordinarily heroic and self-sacrificing, they literally drag her bad ass to the finish line at the cost of their own lives, so that she can survive as a symbol, and the rest of you dummies think she is the hero. Only a taught narcissistic psychology would SEE her as heroic when right in front of you and your eyeballs you can observe she is the least heroic of all. I'm not blaming you, this is the training we all got. The sleight of hand of such movies is that it presents an entirely different society (full totalitarianism) in the context of TODAY, in the context of narcissism as expected, as ok, so meaningless acts become exciting and meaningful acts are obscured. Huh, Mags blew herself up with poisoned gas. Ah well, she was old.

But in totalitarianism, there are no individual acts-- that's the whole point of the totalitarian structure, that's what it wants, what it wants you to become. Your acts appear personal and individualized but conform beautifully, they are no threat. It would NEVER occur to a real Hunger Games hero to show off for upper management, which is why no one else did it, that would be a meaningless act, only we today would applaud this, which we did, loudly. Badass. Not to go ancient history on you, but Achilles was the equivalent of a comic book superhero to young boys for two thousand years, it would never have occurred to any of them to applaud him for his trick shots. It wouldn't have made sense. It doesn't make sense. It is madness.

There are some earnest attempts to apply Game Theory to the Hunger Games, what is the optimal solution? But unfortunately the people who do this are bad at math. Let me try to explain. If 2 tributes are to be randomly selected from a District of, say, 1000 people, then the probability of you being killed is...... 100%. You can double check me if you want, but the math is correct. And-- and this is the point-- the math becomes correct if and only if you think it isn't.

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===== ====== ===== The Last Psychiatrist: I Am Tiger Woods, Part 1

my next endorsement will be from adidas

Question: why would any of these women sleep with Tiger Woods?

"Well, because he's TigerWoods. Maybe they do it for the story, for their ego; maybe they do it because they think he might give them gifts or money; maybe they think he might marry them..."

So it couldn't possibly be because they like him? That had they not known about his fame and money, they still would have gone to bed with him?

"Of course not. Not those girls."

I see. Do you think he doesn't know that?

II.

Assume Tiger was not married. Describe the woman you think would love him "for him." For whom Tiger's fame and wealth plays no part at all, who would have loved him even if he was a shoe salesman. Which modeling agency would she have been with? Oh.

Would Elin Nordegren have married him if he was just Tiger Woods, not TigerWoods?

What do you think Tiger Woods thinks?

III.

Would these women have slept with him if he was half as rich and half as famous? How about 1/4? At what point would he have been insufficiently rich or famous for them?

Yet it is entirely safe to assume these women have slept with other men who were neither famous nor rich. So why did Tiger have to be TigerWoods to get them?

Do you think Tiger Woods doesn't wonder this?

Stop reading here. You should go get a glass of water. Take a nap, watch a music video, there's a catchy one I quite like by Akon/David Guetta. Come back when you've thought this through.

IV.

It may, or may not, be true that these women are golddiggers, "whores", or only interested in him because he is famous; but it is absolutely a fact that these women could be seduced by a man who isn't famous or rich.

The reason this is absolutely, incontrovertibly a fact is that these women are human beings. They have the same general needs-- love, lust, attractions, loneliness, childhood dramas... Different things make them happy, in different ways.

Tiger Woods does not seem to know this. He seems to think what every guy has at least once said: "she only wants a [adj] guy..."

Taken to the inevitable conclusion, Tiger Woods needed one billion dollars in order to think a woman would want him. In order to get those women, he [thought] had to be TigerWoods, not Tiger Woods.

This means that no matter who/how many women he sleeps with, he will never be satisfied, because he has tricked them. He wants them to like him, but he knows they only like TigerWoods. That would be okay if he was just after the sex, he'd have a one night stand and disappear; but instead, he tries to forge loose relationships that are based on him pretending to be his image. This always fails.

The question isn't how he could have cheated with ten women; the question is how he managed to keep it under 100.

Va.

"But if I say I'm a doctor, she'll want to sleep with me." No, that only works on patients.

Vb.

No, I'm not kidding. I'm not saying she has to be your patient...

VI.

"As a woman, what I want to know is why he would ruin what looks like a perfect marriage to a beautiful woman, he has two kids with her... why would he risk all that on cocktail waitresses, no matter how attractive they are?"

Oddly, no man ever asks this question. It's not because he knows the answer: he doesn't. "Well, if I was TigerWoods, I'd probably do the same thing." That's interesting, you didn't say you'd do the same, you said you'd do the same if you were TigerWoods.   "No, I mean in the same situation as him." You mean the one in which you're a billionaire golfer married to a swimsuit model? Or do you mean if you were just a regular guy?

"But it wouldn't happen to me if I was a regular guy, it would only happen to someone like TigerWoods."

That is exactly what Tiger Woods thinks, too.

(part 2 here)

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===== ====== ===== The Last Psychiatrist: I DO NOT CENSOR COMMENTS, MY DAMN SPAM FILTER DOES

That said, someone hates me, fairly I guess, and I respond, not exactly, but worth reading.

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===== ====== ===== The Last Psychiatrist: If Bipolar is Kindled Than You're In Trouble

Tolerance develops to benzodiazepines-- and every other antieplieptic, according to the new Epilepsia article.
In general, efficacy to all AEDs decreases with long term exposure. That's tolerance. If being on an AED reduces seizures by 50%, then tolerance is defined as occuring when you return to less than 50% reduction of symptoms. Thus defined, tolerance (of such severity that increased doses do not help) occurs in 10-50%.

Worse, there appears to be cross tolerance. For example, and likely most significant for psychiatric patients, Depakote "lost >50% of its anticonvulsant efficacy in mice pretreated twice daily for only 3 days with [benzos]."
Why does tolerance occur? On the one hand is the obvious metabolic concern-- autoinduction of hepatic enzymes-- but this is really only relevant with the first generation drugs (and especially CBZ and phenobarbital (these are such powerful inducers of cytochrome enzymes that they actually induce their own metabolism)-- while Depakote is the opposite (inhibitor of cytochromes-- which is why you must reduce the initial doses of Lamictal when given with Depakote, so as not to "overdose" and increase the risk of rash)). On the other hand are pharmacodynamic effects, which are of three types: downregulation of binding sites; functional uncoupling (on the GABA-A receptor, benzo binding has less of a positive allosteric effect on GABA binding); downregulation of or decreased sensitivity of ion channels (for example Neurontin downregulates Ca+ channels, benzos reduce Cl- channels, etc.) Activity on the ion channels (as opposed to receptors) would partially explain cross tolerance since these ion channels are the downstream target of many drugs.
No, wait, there's a fourth reason for "tolerance:" maybe the seizure disorder itself changes over time, so it looks like you became tolerant, but really you have a "new" seizure disorder.   This is analogous to bipolar disorder, which evolves over time-- how you present at 25 may be different than 35; your manias are different, etc.
So now we have a problem: is there any reason to think that tolerance to the antimanic/antidepressive effects of AEDs wouldn't occur? If seizures, why not mania? If mania is a strictly biochemical dysfunction in the brain, shouldn't tolerance to its treatment occur? Do we make patients worse by keeping them on the meds? Or at least harder to treat? And if mania isn't strictly biochemical-- if we're allowing that life happens-- do we really believe that a fixed dose of an anti-epileptic administered over years is going to prevent a negative response to a life event? And wait a second-- doesn't mania spontaneously remit even without medication? Shouldn't we just, sort of, help nature along, or even get out of its way?
I'm not saying not to treat-- I'm saying not to overtreat,
A guy is on 1500mg Depakote today. What do you do when the patient relapses?   Increase to 2000mg? Then what? When does it stop? When does this practice not ultimately result in polypharmacy?
Any reason-- biochemical or epidemiological, I'll take any offer-- why we should not be treating symptomatically rather than prophylactically?   Antimanics when you're manic, then stop them when you're better?
I know everyone thinks Osler helped write the DSM after finding the gene for psychiatry and Hippocrates is jealous because he's balding junior faculty , but perhaps we should go reread The Epidemics and rethink our principles.

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===== ====== ===== The Last Psychiatrist: If France Gets Its Way, 38 Million People Will Die

"All of healthcare is in crisis." Well, Chirac is not helping matters.Healthcare policy has two concurrent and dangerous trends developing. In the first trend, as detailed recently by Dr. Marcia Angell in the New York Review of Books ("The Truth [sic] About Drug Companies") is the pervasive notion that pharmaceuticals are a need and a right, and cannot be left to the drug companies to disburse with an eye to profits. Leading us to the second trend, as evidenced by France's recent swipe at the U.S. for not allowing poor countries to bypass patents and create cheap generic HIV drugs, which specifies that when medical need arises, government should be allowed to commandeer treatments and prices for the good of the people who need the drugs. Looks like the old argument: social justice vs. personal responsibility. Except the argument isn't grounded in reality. Saying something vague like "people need these drugs," misses the immediate point: which drugs? On what grounds is it even possible to say that people "need something" that didn't exist until a company created it? Under what circumstances can we say people now need a drug that won't be invented for another 10 years?

The problem, in part, in this debate arises from scientists confusing discovery or research with invention. Looked at in terms of the production of novel material, certain distinctions can be made. Discovery and research are not creative acts. While they require creative thinking, they do not add anything materially new to the world. Alternatively, invention is the act of creating something that did not exist. There was no Prozac or Tylenol until someone invented it. You may think the rainforests have all the cures, but they don't. As of right now (things could change) the law appreciates this, and only allows for the grant of the patent right when the invention in question is new, useful, and not obvious. However unfair this may seem, that is the system. Ordinarily, no one debates what is new or useful. Obvious, by contrast, is the source of much debate. Can something be not obvious if it was the logical next step? Or if someone else would have done it sooner or later? Many do not understand this debate, lamenting the unfairness of assigning property rights in science "when discoveries that depend on generations of prior science are patented by the person who made the last step."

This is the classic mistake. The last step is not obvious before it is taken. Perhaps there exists an example of a patent in which the inventive step was obvious to everyone before the inventor himself took that step? It seems obvious now for surgeons to wash their hands before operating, but tell me, why wasn't it obvious to the doctors who performed surgery in the hundreds of years before the practice was conceived? It is common in many fields to look at patents and say "oh, I could have thought of that." This is impermissible hindsight, because the determination of obviousness can't be made after the fact.

I suspect, however, that the current debate among politicos over drug patents has little to do with the assignment of property rights (which is best left to lawyers and judges skilled in the practice of assigning rights generally). Rather it is a land grab to curry favor with voters at the expense of the health of future voters. This is what is so damaging about the controversy over HIV drugs. The drugs exist, and they are needed now. But how to hand them out?

Note that the debate is not about changing patent law with respect to future drug patents. Rather, the debate is over changing the laws on existing patents for successful and safe drugs that were developed under the assumption that the patent to them would last 20 years.

This is "patently" unfair, because it amounts to changing the rules after the game has already been won. Drug companies invest hundreds of billions to create (not discover - create) these drugs. Scientists like to dismiss this part of the argument, because they feel that crass commercialism sullies the purity of science. This is as childish as it is preposterous. Scientific research is massively expensive. The investment is made by investors who don't care about science, but do care about returns, based on the understanding that anything they invent they will be able to sell exclusively, at least for a while. To threaten abrogating the patent right for successful drugs, or artificially manipulate their prices will cause investors to pull out of drug companies now and into more predictable and less regulated industries. This will reduce the investment in future drugs. You don't appreciate the strategic problem here, because the future drugs that will never get invented don't exist, so it does not seem like you are losing anything.

But you are.

If you do not think that this is true, consider the fact that many of the newest drugs are cosmetic or lifestyle drugs, like Viagra et al, or are "me-too drugs" (other versions of the same kind of drug, i.e. 5 different Prozac like drugs.) Drugs which treat conditions that are not life-threatening and which are therefore not prone to federal or HMO price control. Compare this to the fact that drug companies invest comparatively little in new antibiotic research to combat the well-known problem of drug resistant bacterial strains. Public and social policy has distorted the market and predictability of patent rights, so drug companies stay away from research that is likely to become a political issue. Why bother investing to invent an antibiotic (or HIV drugs) when it could be commandeered by the government because it is "needed?" And the public suffers. It is convenient for France to demand the commandeering of the patent to HIV drugs to allow for cheaper generics. But current HIV drugs are not curative. Who, exactly, does France expect to invent the actual cure--- that will then likewise be commandeered? In a flashback from the Fountainhead, France wants to take credit for charity that someone else will pay for.

Would you rather have Viagra or a new HIV vaccine? Both are a question of money, but if you are going to place a value judgment on one over the other, then you have to incentivize the drug companies to do what you want. At the very least, you shouldn't disincentivize them.

Good drugs cost a lot, and we are going to have to pay it. Period. Because the alternatives are completely unfathomable: that good drugs are never invented; or, that they are invented but kept secret. Maybe they are used only to cure members of one's family, or race, or class, or religion. That is perfectly legal, by the way. France should think about this before they sentence millions to death.

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===== ====== ===== The Last Psychiatrist: If I've Won Cronkite, I've Won America

PFC Jessica Ogilvy

Yesterday, on the Ron & Fez show (XM202-- this is a stellar show), the director of The Tillman Story was interviewed. The Tillman Story is a docu-drama on the the cover-up of the death of Pat Tillman.

I haven't seen the movie yet; but something the director said to host Ron Bennington completely floored me.

If you can remember the Jessica Lynch story, she was ambushed and attacked by Iraqi soldiers, and, apparently, ninjas, who stabbed and tortured her and then hospitalized her. Then came the daring rescue operation with Rangers and Seals, the first ever military rescue of a POW (?) We've since learned that that there were no ninjas in Jessica's ambush, and the rescue footage was staged and edited by the military.

"this is impressive"

That the military would manufacture the truth doesn't surprise me. I've seen enough action movies to know that a) it's always a cover-up; b) it goes all the way to the top. Poor Arnold Schwarzenegger, an Austrian immigrant, was the victim of a military cover-up 11 times between 1984 and 1999. It's a wonder he wasn't later killed by a drunk driver in a terrible hit and run accident, but I guess they figured keep your enemies closer.

Sully chose to take the blue pill

Because of the 2007 Congressional hearings, we have finally been able to see the real, unedited footage of that rescue, and it shows... well, it's boring. No bad guys, no radio for air support, no one needs to shoot two pistols at once. They do actually get her, but you clearly get the sense that this less for Jessica's benefit than for the camera's.

I know, I know, it was Evil George Bush and the Republicans hiding the truth, trying to get us flag waving. For the record, I didn't expect it to change at all under Obama, and so far so right. No one who sits in that chair is going to willingly give up any power. He can barely make things work with all that power, "how am I going to do this with less?" Power corrupts and absolute blah blah blah. Maybe instead of pardons, an outgoing President could sign away powers?

So this is what the director of The Tillman Story said, and I'm trying to quote from memory:

Ron: And the other thing I found fascinating was how the news networks went along with it.

Amir: I'm so glad you brought this up, because this is really the real story. That unedited footage (of Lynch's rescue) we show in the movie didn't come from some undercover/hacker network, it wasn't Deep Throat-- we got that footage from the regular news media. They had both the edited and unedited footage the whole time, but they chose to run the edited footage because it was more dramatic.

Holy crap. You almost expect it from Fox News, ok; maybe even CNN, they just want ratings, fine. But did no one in 2003 think to show the unedited footage? Even selfishly to boost their own ratings, did no one try to make the story, "Hey, Look, the MSM Is Lying To You!"

When they pretend not to know the truth about some pop culture story, the real shame is on me for expecting truthful reporting on nonsense. But for the media to pretend not to know the truth about something like this-- dozens of news outlets, all playing chicken hoping no one blinks first and tells the truth...

II.

There's a lot written about the causes of the failings of the Froth Estate: beholden to ratings, a dumbed down America, having to compete with other media, but I submit a slightly different cause: there's too many of them.

Back in the day, when there were three networks giving America the news, if any one of them went a different way, it would have been big news. "If I've lost Cronkite," President Johnson maybe said, "I've lost America" and he was right for a different reason than he meant: he wasn't the window to America, he was the filter of the information. Cronkite wasn't filtering anymore.

In fact, the intellectually snobby thing to do circa 1969 was pretend to read the foreign press. If you read Le Monde you were sophisticated, and if you read Izvestiya and Pravda-- smuggled out or transcribed from memory, of course-- you were outing yourself as an intelligence analyst.

Now there are news outlets everywhere, all competing with each other-- hence the focus isn't truth but survival, and survival means more boob pictures and a willingness to play by the government's rules because if they cut you off, you're done.

There's an even worse factor in play: the multitude of news outlets makes you think they're all checking on each other, that even if one gets it wrong the other 19 won't. But most are getting their story from the same single source, the AP.

"So where do we go for objective news?" I don't think that's the question, because the market requests it, and the way to get the market to request it is for all of us to be aware of the tricks and manipulations of media.

I make fun of John Stewart because it seems silly to me, but maybe shows like his are the only thing standing between us and, well, CNN.

---

http://twitter.com/thelatpsych

===== ====== ===== The Last Psychiatrist: If These Guys Aren't Invested, Then It's Over

Late last night I saw National Georgraphic: Inside The Green Berets. The platoon was having a memorial for one of the Berets who had just been killed by an IED, and the Green Beret giving the eulogy says, "he wasn't just fighting for his country, he was fighting for a higher cause-- he was protecting each of us."
Army of One, I guess.

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===== ====== ===== The Last Psychiatrist: If this blog were a book you would give to someone else, what posts would you want in it?
I'd like to take some of these posts and compile them into a book.

The posts would be reworked, sent to an editor, etc.

What I'm looking for aren't necessarily people's favorite posts, or posts that hold up best over time. I'm looking for those posts you wish you could send to someone else, except that they don't read blogs.

Submit your suggestions any way you'd like (twitter, fb, comments here, email).

Thanks for helping me with this.

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===== ====== ===== The Last Psychiatrist: If This Is One of The Sexiest Things You've Ever Seen, You May Be a Narcissist

A quick primer on the new Narcissism.

I don't mean the traditional Kernberg, Kohut, or even Freudian descriptions. In the modern times, I think narcissism has evolved.

A narcissist isn't necessarily an egotist, someone who thinks they are the best. A quick screen is an inability to appreciate that other people exist, and have thoughts, feelings, and actions unrelated to the narcissist. These thoughts don't have to be good ones, but they have to be linked to the narcissist. ("I'm going to get some gas-- because that jerk never fills the car.")

The narcissist believes he is the main character in his own movie. Everyone else has a supporting role-- everyone around him becomes a "type." You know how in every romantic comedy, there's always the funny friend who helpes the main character figure out her relationship? In the movie, her whole existence is to be there fore the main character. But in real life, that funny friend has her own life; she might even be the main character in her own movie, right? Well the narcissist wouldn't be able to grasp that. Her friends are always supporting characters, that can be called at any hour of the night, that will always be interested in what she is wearing, or what she did. That funny friend isn't just being kind, she doesn't just want to help-- she's personally interested in the narcissist's life. Of course she is.

A comedian I can't remember made a joke about actors in LA, but it's applicable to narcissists: when two narcissists go out, they just wait for the other person's mouth to stop moving so they can talk about themselves.

So on the one hand, the narcissist reduces everyone else to a type, as it relates to himself; on the other hand, the narcissist, as the main character in his movie, has an identity that he wants (i.e. he made it up) and requires all others to supplement that identity.

A narcissist looks the same every day; he has a "look" with a defining characteristic: a certain haircut; a mustache; a type of clothing, a tatoo. He used these to create an identity in his mind that he will spend a lot of energy keeping up.

Consider the narcissist who wants his wife to wear only white, high heeled pumps. The narcissist wants this not because he himself likes white high heel pumps-- which he might-- but because the type of person he thinks he is would only be with the type of woman who wears white high heeled pumps. Or, in other terms, other people would expect someone like himself to be with a woman who wears those shoes. What he likes isn't the relevant factor, and certainly what she likes is irrelevant. What matters is that she (and her shoes) are accessories to him.

Never mind that the woman is obese, or 65, or the shoes out of style, or impractical-- the shoes represent something to him, and he is trying to reinforce his identity through that object.

Narcissists typically focus on specific things as proxies for their identity. As in the example above, that the woman might be obese or a paraplegic could be ignored if the footwear was the proxy for identity. These proxies are also easy to describe but loaded with implication: "I'm married to a blonde." Saying "blonde" implies something-- e.g. she's hot-- that might not be true. But the narcissist has so fetishized "blondeness" that it is disconnected from reality. The connotations, not the reality, are what matters (especially if other people can't check.)

This explains why narcissists feel personally sleighted when the fetishized object disappears. "My wife stopped dying her hair blonde; but when she used to date her other boyfriends, she was in the salon every month. Bitch." He doesn't see the obvious passage of time, what he sees is part of his identity being taken from him, on purpose. Here's the final insult: "she obviously doesn't care about me as much as her old boyfriends."

As a paradigm, the narcissist is the first born (or only) child, aged 2-3. Everything is about him, and everything is binary. His, or not his. Satisfied, or not satisfied. Hungry, or not hungry. Mom and Dad are talking to each other and not me? "Hello! Focus on me!" Youngest children don't typicaly become narcissists because from the moment of their birth, they know there are other characters in the movie. (Youngest more easily becomes borderline.) Control, of course, is important to a narcissist. If you can imagine a 40 year old man with the ego of a 2 year old, you've got a narcissist.

Obviously, not all first borns go on to be narcissists. Part of their development comes from not learning that there is a right and wrong that exists outside them. This may come from inconsistent parenting:

Dad says, "you stupid kid, don't watch TV, TV is bad, it'll make you stupid!" Ok. Lesson learned. But then one day Dad has to do some work: "stop making so much noise! Here, sit down and watch TV." What's the learned message? It isn't that TV is sometimes good and sometimes bad. It's that good and bad are decided by the person with the most power.

So the goal in development is to become the one with the most power. Hence, narcissists can be dogmatic ("adultery is immoral!") and hypocrites ("well, she came on to me, and you were ignoring me at home") at the same time. There is no right and wrong-- only right and wrong for them. He's an exaggerated example: if they have to kill someone to get what they want, then so be it. But when they murder, they don't actually think what they're doing is wrong--they're saying, "I know it's illegal, but if you understood the whole situation, you'd understand..."
Narcissists never feel guilt. Only shame.

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===== ====== ===== The Last Psychiatrist: If You Are Surprised By Vioxx's Risks, You're Fired
This was an op-ed I had written two years ago. In light of the 12th trial win for Merck (they chose to fight each suit individually, rather than settle a class action), I'm reposting it here.

In the current politically polarized climate it is no surprise that yet another story of the evils of Big Pharma should surface. And why not? When everyone else abdicates responsibility, the easiest maneuver is to scapegoat the ones who actually create anything.

Consider the Vioxx debacle. By now, everyone knows that it was recently discovered that taking Vioxx is associated with an increased risk of heart attacks and strokes. What is not obvious from the news is that the data used to make this discovery has been in the public domain for years. I even found it in a Yahoo! News article from 1999.

Merck halted a recent trial because it detected this increased risk; but other studies had already found this same risk even four years ago. So why now? And why are any doctors surprised? Were they not reading the journals all along? Were they simply accepting the word of the drug companies? But a recent New England Journal editorial goes further, blaming the Merck and the FDA for failing to protect the public. You’re blaming the FDA? Is the FDA prescribing the drug? Again, the data was already available to anyone with internet access. The fact is that any doctor who is surprised by the “new” data on Vioxx’s cardiovascular risk should never have been prescribing it in the first place.

The Journal goes on to say that Merck tried to minimize the significance of the risk. Even if true, it is irrelevant. The data was available. It doesn’t matter how marketing spins the data, because doctors, as medical scientists, are supposed to be able to ignore marketing and focus on the data. Doctors are supposed to know the data before they prescribe a medicine. Quoth the Journal:“If Merck would not initiate an appropriate trial (to formally asses cardiovascular risk) and the FDA did not ask them to do so, how would the truth ever be known?”
This is a joke, right? Is he seriously suggesting that it is the government’s responsibility to evaluate existing data? Yes: “I believe that there should be a full Congressional review of this case.”

The author fails to separate the responsibility of Merck with the responsibility of the physicians. Understand that I am not trying to absolve drug companies of their responsibility; I am trying to differentiate their responsibility from doctors' responsibility.   Published data becomes the responsibility of the doctor. They are practitioners; their role is to determine, specifically, if the risks of a treatment outweigh the benefits (and vise versa.) If they choose not to read everything available on their own, and to rely on the words of the FDA, or the drug companies, or anyone else—then the fault is the theirs, the liability is the theirs. Ask any lawyer. The data is the data. It doesn’t matter what the drug companies say, or the FDA says, or even what another doctor says, because this is science. it has hard facts I can check, I don’t actually have to trust anyone’s word. Medicine is still a science, right? We’re still sticking with that story?

But this almost never happens in actual practice, hence surprise at the "discovery" that Vioxx has cardiac effects. If doctors had done their jobs and understood, from the beginning, that Vioxx had a minor but still real increased cardiac risk, and modified their use of it (i.e. not hadning it out like water) then Vioxx would still be on the market and this controversy would never exist.

Drug companies are an easy target, because they are large, impersonal, and very, very rich. The zeal which doctors now attack drug companies as “commercial” (seriously?) and “biased” borders on oedipal. This is because doctors do not create anything new. They are not inventors. When the TV tells you that “doctors have discovered a new cure for X” what they really mean is that a drug company has made this invention, and your doctor is using it. But to believe that doctors are making treatment discoveries during the course of ordinary practice completely misses how progress in medicine is made.

This is not to minimize their role; obviously, they are the ones who are doing the treating. But by consistently framing the issue for the public, politicians, and other doctors, as one of doctors against the pharmaceutical industry, or Pharma against the weak and the oppressed, we are grinding progress to a slow and purposeful halt.

Vioxx is an easy target because we don't "need" it. But how do we know that someday they wouldn't discover it cured, for example, cancer? Don't laugh: the trial Merck interrupted to pull Vioxx was for the prevention of colonic polyps. Is that worth the very small (1%) risk of a heart attack?   Now we'll never know. That would have been a decision for doctors to make with their patients. This is the point, the only point. But now, because doctors were not rigorous about their own practice or education, no one gets to try it. Who suffers? Answer: you. And this barely accounts for the massive strategic harm this does to Merck, in lost revenue as well as increased paranoia, risk aversion, etc. It is unlikely that Merck will be as aggressive or spend as much to find the cure for, say, AIDS, tuberculosis, or cancer. Everyone happy with this outcome?

===== ====== ===== The Last Psychiatrist: If You Have To Ask, The Answer Is Neither

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===== ====== ===== The Last Psychiatrist: If You Liked The Descendants, You Are A Terrible Person

i've seen this movie before

The Descendants is not the worst movie ever made, but it may be the most subversive, and if you think it is one of the best you need to rethink your life choices.

Bring a date. Oh, you don't have one.

I.
The promotional tag line:

A land baron tries to re-connect with his two daughters after his wife suffers a boating accident.

You'll observe that the three women are characterized only by their connection to him, while he gets an extra identifier-- that happens to be about his wealth.   We'll come back to this.
The movie is a pyramid scheme of cliches: you can keep heaping them on as long as no one ever asks how it pays off, because it can't. Rich but emotionally distant husband. Complicated wife. Family secrets, summed up by the dumb stoner toolbox improbably dating Matt's (Clooney) smart but rebellious daughter:

That may not read like an insightful exchange between men, but I'll translate: men are never much worthy of their women.
Cue crying, laughing, yelling-- no sing-a-longs, this isn't a chick flick so male emotional progress will be symbolized instead by either jujitsu (wrong genre) or by forward physical motion: driving, walking, running, travel, now we're getting somewhere-- lots of blaming, reconciliation, "resolving of inner conflicts" and of course Act IV "closure."
Love is complicated, death is complicated, and a movie about both would be, well, complicated, especially when you throw in infidelity. But despite what you will hear and read from critics, The Descendants is neither complicated nor about any of those things.
Here's your first hint: it's called The Descendants.

II.

just saying

I am not an expert on what makes a good or a bad movie, if it's bad you'll ignore it and anyway, best case scenario, two minutes after it wins Best Picture it will go the way of Cold Mountain. The real power of movies that do not involve giant robots is not what they tell you about yourself, but that they tell you how to think about yourself. You don't think you learned that from your parents, do you?
This is the "Personal Quote" on director Alexander Payne's IMDb page:

It's my hope that we're getting into an era where the value of a film is based on its proximity to real life rather than its distance from it.

By "proximity to real life" does he mean "was playing 20 minutes away form my real life" because the only commonality between the film and my life is that they are both shot in color. So whose real life is this proximate to and how do they think about themselves? Let's listen.

III.

Here's what happened about 15 minutes into the movie. I'm sitting three or four rows in front of two 50ish women. In a key emotional scene teen daughter Alexandra blubbers through her mixed up adolescent tears that dying mom wasn't happy and was cheating on him. He is floored, devastated-- he had no idea. So he literally runs down the street to a couple that was friends with his wife, and they reluctantly admit that it is true-- and that she was planning on divorcing him. At this moment one of the women seated behind me says, loudly, as if making an important discovery about human nature and I swear I am not making this up, "A divorce! And all that money!"

Son of a bitch, am I an idiot. That thought never occurred to me. It's legitimate, it would be a huge part of divorcing characters' reality, and I missed it because, dumb stupid me, I was thinking this was about love and infidelity. But of course it isn't. At all. On second viewing (thanks Sweden) it's obvious. There is no love depicted anywhere in this film and its target demo knew not to expect it, not to look for it. Yes it's about family and sadness and betrayal but love? Middle aged people don't love, duh, love is for 20 year olds. Besides, what does that demographic know about love anyway, where would they have learned it?   The rom-coms all ended right when the relationship begins. There's no consistent model for love ten years after marriage, except ones based on: infidelity, divorce, death, finances. Which is exactly why the first two happen so often in response to the second two.
The few happy movies about mid-life "love" are not about established marriages (those are always sitcoms) but about new relationships, starting over, new beginnings, play-acting the story lines of their twenties but with a "mature" take, i.e. some middle aged mother of two looks in a mirror before her first big date in years and laments how old she is now and how ugly she's gotten, as played by Nicole Kidman or Jennifer Aniston. Wow, nailed it, I can completely relate. I'm not knocking these movies for existing or for casting these hairless nymphomaniacs, I'm simply posing the general question: since the audience has learned nothing from their own parents, and they don't read 19th century Russian literature, what is their model for love in the 2nd decade of marriage? They don't have one. Which is why when this demo finds themselves in the 2nd decade of marriage they feel unfulfilled, anxious, depressed, is this all there is? They have nothing to guide them except The Discovery Channel and mommy blogs, and they lack the courage to analyze their ennui, so these movies serve the important function of pretending that it's normal. "Oh, yeah, that's exactly what I'm feeling." Fine, but don't you also want to know why you feel that way?
There are, of course, plenty of people with normal marriages who still love each other despite the absence of windfall inheritances and relentless drama. But they won't be seeing this movie.
Normal love between two normal people that is not clandestine or inappropriate or impossible or financial is not revealed here, it is not even imagined here. The couple with the "best" marriage-- and no whites in this movie have a good marriage-- are the wife's elderly parents, but don't worry, no love there either: mom has severe dementia, so dad is her caretaker. That may sound like love but that odd backstory means that no male in this movie is ever depicted dialoguing meaningfully with a female of his age group, unless they are arguing. And no one notices this weird feature of the movie's world because that's the world the audience lives in as well. And what does this grieving but wise old former soldier say to Clooney about his daughter's infidelity and death? "If only you had let her go on those shopping sprees women like, maybe she wouldn't have needed to get her thrills elsewhere." I wish I made that up. Life is priceless, but for everything else, there's Mastercard.
These depictions of mid-life's relentless pragmatism, isolation, and lack of anything-- what word can I use that doesn't bring out the psychotics?-- "abstract," dressed up in porno-level dramatics to mask the banality of it all are no more realistic than a fat guy's second chance with the girl that got away (Charlize Theron), and yet they resonate with a certain audience because that's where they live, too.
In fact, the only psychologically realistic thing in this movie, and not coincidentally it will be the one thing the audience will say is the least realistic thing-- is that the older generation is so emotionally infantile that their children become parentified. Example: Clooney passive-aggressively calls his wife's lover and leaves a message pretending to be a client, and when the guy calls back Clooney's paralyzed; so his daughter takes the phone (NB: a Blackberry) out of his impotent paw and runs the con. Manipulating middle aged men for middle aged men. Just the right role for a 16 year old girl. It'll be easy to tell her drinking is bad now. NB: the girl's mother is dying in the same room, but it's the father that needs all the attention. She has to be strong for him. "Save me Anna Freud, save me!" In fact, according to the movie, here is how teen girls cope with the loss of their mother: they get over it. It takes about 15 minutes.
It's supposedly judgmental to say that Matt is a bad father, you're supposed to say, "he's doing the best he can," which means that it's okay he's a terrible role model because by golly he gets points for admonishing the kids not to curse. "Watch your language," he says a lot. HA! That's the movie's comic relief but it's also some BF Skinner 10th dan ninjitsu. Control of expression-- language, behavior, appearance-- substitutes for parenting, it's not for the kid but for the parent, it makes the parent think of themselves as a parent because the outside looks all presentable, and then they are just so surprised that their micro-parenting didn't prevent their ADHD teen from turning to alcohol. "It's a disease." I'll get my stethoscope.
"Who are you to blame me my teen's behavior?"   I don't even know you or your teen. YOU ARE PROJECTING. All I'm saying is if your teen is an alcoholic AND you think The Descendants is a meaningful film, then you need to bring to your therapist of ten years the possibility that the two may be the same force and that the problem isn't your teen, or your exes. They weren't Matt's, after all.

IV.
Voice overs are supposed to be an example of bad or lazy writing, but I have a theory: when a movie has a voice over, it means the character is being dishonest. Not "it wasn't me who stole the cookies" dishonest, but "it's not as simple as it looks, you don't know the whole story, let me explain" dishonest. In other words: BS. This can be consciously manipulative (The Usual Suspects) or unconsciously rationalizing (Sex And The City). The voice over pulls you into the mind of the character and so you are less able to make an objective assessment about what you see. What's important about it is that the story would be impossible to tell without the VO because no one would buy it. I can see why director Alex Payne needed it for this one.
Here's a bit of human nature for you and you are most certainly not going to like it. Fat George Clooney discovers his wife has been cheating on him-- and he never suspected. That's a profound insult, a narcissistic injury, and no, people who complain I talk about it too much but haven't actually learned the lessons, you don't have to be a narcissist to experience a narcissistic injury, it's built into the way we relate to other people. It's jealousy AND an existential beat down: look at the limits of your power, look at the limits of your reach, she is able to have a whole other existence that had so little to do with you you didn't even notice, nor did she feel any need to tell you. At least if she had done it to hurt you you'd still suffer the jealousy but your place as main character in your own movie would be secure. Maybe you're only supporting cast in hers?   "Screw that. I'm changing the script."
Three ways humans deal with narcissistic injuries, count them: 1. Rage. But Fat George Clooney doesn't look like he's up for the physical exertion of attacking his wife, which is why he is depicted as fat and not fit (viz Sleeping With The Enemy, Unfaithful, The Last Seduction, To Die For, etc) and anyway the target is in a coma. 2. Displaced rage: go after yourself (suicide: guarantees the Other remembers you forever) or the lover. But if Fat George Clooney is too winded to beat up a coma patient, how's he going to fight the Alpha Penis that stole his wife? Pass. What he might do-- which is both highly realistic about the target demo and also the problem with the target demo-- is channel his inner 15 year old girl and stalk him, then kinda-sorta confront him, then mess up his stuff. That'll show him.
The third way is the interesting one, the one that ruins you: 3. Make the cheating be about yourself, your "fault" (minus any real introspection.) Increase your pain to save your ego. That's the path the movie chooses: she cheated not because she fell in love, or lust, but because he neglected her, he was a bad husband, he didn't take her on shopping sprees.    "As long as you don't ask me to change, I'm accepting some blame for her cheating on me." You'll feel right as rain.
The movie takes this a diabolical step further. Matt finds and confronts the lover, but in an act of "selflessness" tells the guy he's not there to cause trouble, he just wants to give the guy the opportunity to say goodbye to her, too. WOW! What a guy! And no one thinks this is preposterous. The audience sees this as a redemptive act, a kind act, a noble act, and that's because they are all idiots. No, no, I mean every single one of them. They are (thanks, VO) starting from a false premise: that he actually really loved his wife in the first place. He didn't. That's why she was cheating. To illustrate just how inconceivable "love" is to this audience, I'll explain that this selfless offer is how the scene starts, but the point of the scene, how it ends, is with Clooney realizing that the guy bedded her for his money. So not only did she cheat because of him, the lover chose her because of him. Narcissistic injury averted-- that's what passes as "coming to terms with" infidelity for this audience.
While the 50 year old women behind me and every critic in America are applauding his apparent selflessness, they overlook the fact that while he wasn't angry when he confronted the lover, he became angry when he discovered the true target was his finances. That's what gets him fuming, and that's what makes sense to the audience. Penis and vagina are all very well, but if you mess with the inheritance, it's personal.
Also observe that the lover is not better looking than Matt, not richer than him, not more interesting than him, in every way Clooney is "better" than him. This is a movie so it was scripted this way, but when your wife cheats on you you'll do the same thing, so remember what I'm about to tell you. You will "discover" how much better you are than him in every way so that her cheating is explicable only as a reaction to you. You will cry, you will drink, you will yell and you will rage, but you won't kill yourself and you won't change and that was the whole point. The ego doesn't want happiness, it wants status quo. Yes, you will also simultaneously disparage her as a bitchless cunt, but that's because she did it to you, against you, towards you. This will help you eventually "come to terms with" her infidelity, but what then did you learn about yourself? What then will you change about yourself? Nothing. Hence the sequel will be the same as the first movie, with a different villain.

V.

"This is the first movie review I've ever read that attacks not the movie but the people who liked the movie." I'm not attacking you you if you liked it, only if you identified with it. "That's not really fair." American Psycho was an amazing movie, but I wouldn't date anyone who identifies with it. How is it different? Again, the point isn't that movies tell you who you are, they tell you how to be.
Here's an example: with 100% certainty I can predict that if you liked The Descendants, if you think you would like The Descendants, then you thought American Beauty was "amazing." That movie was, indeed, an outstanding reflection of a kind of a man and a kind of a life, but at some point before your divorce or rehab you have to consider that if you identified with the main character there is something wrong with you.

Anyone exhausted? Here's a comedy break (NSFW):

Louis CK:
Kevin Spacey playing the man... he's fantasizing about fucking a cheerleader in high school. And the way they represent this, in this gay movie, this fucking bunch of cum through a projector-- according to this movie, when you fantasize about a cheerleader, you lie on your back and rose petals fall all over your body. Instead of her hot, sweaty ass, and the confused look on her face as you cum in her stupid eye... No, it's Kevin Spacey with a sweet look on his face, and flower petals, and jazzy music.
[And at the end of the movie, the ex-marine] is the one who's really gay. 'None of us are gay, it's actually the one hetero guy, he's the gay one.' No one else is gay, Kevin Spacey's not gay. He's straight as an arrow, he lifts weights, listens to Zeppelin, drives a Firebird-- and thinks about fucking rose petals. And then when he actually sees her tits he almost vomits....He finally sees the 18 year old tits and says, what have I been doing all this time? I forgot I like men....

Louis CK takes the gay angle for the comedic effect, but he understands this isn't about being gay but about a kind of American self-delusion exemplified by the Kevin Spacey character: everyone else is broken except me. My only problem is I am surrounded by these people. And everything gets projected onto them as both defense of the ego and as confirmation that it is, indeed, everyone else who is nuts. "Look, she's a crazy bitch." When he throws the plate of food against the wall you're supposed to cheer his rising manliness; you're not supposed to notice that it's infantile narcissistic rage, i.e. foreshadowing: this isn't going to have a happy ending. The problem for the audience is that there isn't an American Beauty II, the one where he gets the rose petal girl of his dreams and inherits a billion dollars and has a perfect life in Hawaii only to discover that within 5 years everything has regressed to the mean, I mean mean, and everything happens all over again. "Jeez, why do I attract these crazy bitches?" Because you're crazy, dummy. The one universal constant in all of your failed relationships is you.
At the end of The Descendants Clooney and his daughters have "overcome" or "moved on" or "come to terms with" it all. But in fact nothing has changed.   And what has at-the-end-applaud-worthy-Dad taught his kids about human relationships? What kind of a man do you think Alexandra is going to eventually marry? How soon afterwards will she divorce?
Remember Clooney was going to forgo revenge and instead generously let the lover say goodbye? Well, at the end he gets his revenge anyway, in the only way meaningful to the audience: he screws the lover out of money.

Think about this. You'd do it, too, if the opportunity presented itself, but that's not the point. The point is that this is a movie and hence not random, the movie chose this method of revenge. It is satisfying to the audience, but the kind of person to whom it makes sense to punish a wife's lover financially is the kind of person... whose wife has a lover. He will have revealed to his wife in countless other ways the transactional value of her sex, and while it may be a lot it's still finite, and so she will get the message and eventually Trade Up to an equivalent model that costs her more. Indecent Proposal had the decency to put love over money at the end, but that didn't stop a gazillion women from shamelessly/proudly announcing how fast they'd "totally go for it", as their whipped boyfriends sat on the bar stool next to them hiding behind a frozen smiles and pints of Sam Adams. "It's a Winter Brew." Choke on it, cuckold. Meanwhile none of the giggling women in the bar seemed to remember that Robert Redford was offering the money for the wife to the husband. The trick to understanding that movie is that it isn't a female fantasy to have a rich guy offer you lots of money but a male fantasy to have a rich guy value your woman's sex at $1.57M inflation adjusted dollars, it makes the mystery of sex/"objet petit a" a concrete and understandable commodity but also puts it fantastically out of your own reach, like you're 12.

The reason no one remembers that Redford made the deal with Woody and not Demi is that it is unremarkable to these people that that's who he would make the deal with, nothing unusual or noteworthy there, Woody is the proper owner of Demi's sex. Yeah, they're married, that's how it works. I can see you're upset. I know, reality bites. Take a drink, and consider that in The Descendants Matt's relatives are all waiting for him to sell the land so they can get their cut, and Matt's hesitant, and then says something the dummies in the audience didn't appreciate, and what he says is this:

Way to figure this all out way too late and about the wrong thing. The land is supposed to be a metaphor for legacy, for doing the right thing with your inheritance, but I hope it is obvious that the land is a metaphor for vagina. You may have got it for whatever bullshit reason 150 years ago, but now as the owner of that landgina you have a responsibility to tend to it. So yes, it makes sense that the rival thought of it as a means to money, it makes sense that the Medicare patient's first thought was to alimony, and it makes sense Woody was willing to sell Demi, it makes sense Matt is more attentive to his finances then his wife, because if you don't tend to that vagina, to that soul, then all that's left is it's resale value. And it all makes sense to the audience, because they're psychopaths. Is that too harsh? Didn't they get choked up when she dies? The Descendants has a sad ending, and it makes you sad. That's not the sign of a well crafted movie, it's a kind of porno. That's why they're called tear jerkers. If you bludgeon a puppy or penetrate a vagina you do not then get to yell, "Ha! Made you look!"

I will concede, however, that the ending of The Descendants couldn't be a more accurate representation of the generation that is only able to feel rage, sadness, anxiety, and nothing. The last scene of the movie, symbolizing how one moves on from death and infidelity, shows Matt and his daughters, inheritance intact, watching TV. Roll credits. Oscar.

-----

see also: The Strange Ascendance of The Descendants

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: If You're Drinking Decaf, You're Probably Too Tired To Read This
The NYTimes has a short piece about their recent discovery that decaf coffee actually has caffeine. Well, ok.

They cite a study in the Journal of Analytical Toxicology (from 2006) that found that

They also tested 6 cups from the same Starbucks (one in Florida) and found 12mg/16oz.

The article also references the recent Consumer Reports article testing of 6 cups each of 6 different brands of decaf. Here's an interesting statement by Consumer Reports:

One of the six cups (12oz) from Dunkin' Donuts had 32 mg; one from Seattle's Best had 29 mg; and one from Starbucks had 21 mg.

What's weird about it is that Starbucks actually tells you there are 20mg in a 12oz cup of decaf. So why did only one of the tested cups have that much? Keep in mind, the toxicology journal article found an average of 9mg/12oz at one store, 6mg/16oz in another store. We can assume the beans are the same, so the answer, obviously, is in the preparation of the beverage, not the decaffeination process. Specifically, temperature and time.

Have you noticed that Starbucks and Dunkin Donuts coffee is so hot it makes you want to punch a harp seal? And do you remember when McDonalds got sued because some damn fool used coffee as an eyewash and burned her corneas out?

And have you noticed that the coffee you make at home is never as good as the one at the store? And never as hot? And never as good?

Professional coffee makers heat the water that goes into the grounds to F195; your countertop bling-bling does 180. Think 15 degrees doesn't matter?

The hotter the water passing through the grounds, the more caffeine; but the more acidic. I'll say it backwards, too: the colder the water, the less caffeine, but less acidic. Did you ever wonder why no one ever orders Starbucks black? It's because they're all dead. If your machine isn't pushing 1200 watts, it's not even trying to extract caffeine from the coffee. It's giving it a gentle misting, like you might to do to a baby, or when cleaning the leaves of a rubber plant, or when peeing on a friend. Or something.

Also, the last ounces out of the grounds are more bitter than the first. They also have less caffeine. You know those auto shut off coffee pots in hotel rooms, that stop dripping when you pull the carafe (and consequently flood because you didn't know you needed to put the cover on to get it to work?) Each cup you pour is different in taste and composition.

That said, coffee on a hotplate burns fast, very fast. So drink fast.

Also see:

What's The Healthiest Coffee To Drink?

"A cautionary tale about working to hard."
===== ====== ===== The Last Psychiatrist: If You're Reading It, It's For You?

I came across an odd ad in one of the psych journals.

It's an ad for Western Psychiatric Institute. I assume nothing in ads is random. Can anyone tell me why she's reading Griffith Gaunt?
===== ====== ===== The Last Psychiatrist: If You're Watching, It's For You

On the Late, Late Show With Craig Ferguson, a joke about "man-ginas," a few drug/DUI references, a Kristy Ally fat joke ("uses her swimming pool to cook spaghetti") and a homosexual reference.

And I think about how TV has changed, things unimaginable 20 years ago are routine now.   I guess they'll do anything to get the coveted youth demographic.

And then I think, wait a second...

II.

It's the easiest logic in the world to follow: racy humor targeting the youth; old people will either not get it or be outright offended, but it's worth it to get the young viewers.

Ok, but there are also going to be a group of older people, maybe in their forties, who are cool enough to get the humor, to like it, but, you know, most of other people their age will be offended, people like their parents.

But here's the sticking point: Ferguson, Conan, and Leno all have an average viewer age of 50. They're not getting the jokes in spite of their age-- the show is written for them.

And it makes sense: the humor isn't more edgy or racy, it's the same stuff we heard 20 years ago from Stern and others, so this isn't a case of targeting the young, it's actually targeting the old.

Example: they picked Jimmy Fallon to replace Leno, theoretically because he can target the youth viewer. But Fallon was funny on SNL a decade ago-- he's funny to people who were young a decade ago. And so he's going to be funny to those same people who are now a decade older. People don't step outside themselves and realize that everything that is being made by 30-50 year olds, which is nearly everything, is actually for 30-50 year olds, even though it appears like it's for 20 year olds.

Here's an example: Chris O'Donnell is Ferguson's first guest, and he comes out in jeans and a suitcoat. Because he's cool, he's younger than he actually is. Actually, no-- he's exactly as old as he is, because the only people who dress like that are people his age or older.

As if to solidify the point, the next guest is Henry Winkler-- the Fonz-- who also is wearing jeans and a sportcoat. That was cool to (actual) kids thirty years ago when Letterman dressed that way, and now those "kids" are old enough to dress themselves the way they always wanted. (Letterman doesn't anymore.)

III.

But this isn't just old people pretending to be young, an innocuous though silly behavior. This is a larger, social trend, a game, designed to promote a fiction.

The game is to pretend that all this media is for the young, so they're targeting the young by acting "young." But it's really for the old-- who still think they are young. They are calming the anxiety of a generation of older people who still think they are young. "Winkler is acting and dressing hip for the kids, and since I get it and dress like that, too, I must be young."   But Winkler is 60. And no one uses the word hip anymore. Get it?

I'm not saying Ferguson isn't funny-- I watch him-- but I have no illusion that I get him despite my age. It's the foundation of televsion: if you're watching it, it was meant for you.

I couldn't have produced the show better myself to reinforce my point: the commercial break between O'Donnell and Winkler was-- please sit down-- Just For Men hair dye. The commercial showed news and concert footage from the sixties and seventies with a voice over, "The generation that said they'd never grow up-- didn't."

TV may say it wants younger viewers, but every commercial was for older viewers.

About twenty years ago I learned the marketing law that young people have all the disposable income-- because older people were saving-- and they spend the most, and you have to go after them. I don't believe that's true anymore. Hell, the fact that it was true 20 years ago means that those young people are older. They're still the consumerists they once were.

And so what we have here is semiotics, a redefining of terms. "Young" no longer means "ages 18-24." It means "old people who did not grow up."

Don't delude yourself that "40 is the new 30." It isn't, ask anyone who is 30. But that's your business how you want to be. The problem is that the actual youth have no idea what to make of aging. How long are they allowed to be adolescents? Pretty long, it appears. What's the reference point for being mature if your Dad isn't?

Clearly this attitude doesn't bode well for capitalism. Older people who are supposed to be more thrifty are spending their money on useless symbols of wealth. Yes, that includes (too big) houses. And the narcissism that I'm accused of seeing everywhere may, in fact, only exist in people over 30.   Twenty somethings are allowed to be quasi-narcissists, and it's also defensive: what do you expect from a teenager whose Dad, overweight, balding, drives a sportscar?   Emotional lockdown.

Patton Oswalt said he'll be the best parent ever by being boring, because their kids rebel. All the cool parents who smoked pot with their kids raised the kids who moved to the suburbs and put warning labels on record albums.

I believe kids demand of adults to be different than them. More stable, more future oriented, more careful with money. Not someone they want to emulate, but someone they want to go beyond. The adult serves as a foundation to build on. That desire to be a foundation-- not a support or a model or a goal-- is lacking in the older people. There's little thought given to multigenerational advancement, that the primary point of their existence is their kids', and their kids' kids, progress. Not a point, not also a point, but the primary point.

So I wonder if the conventional wisdom "we are a youth obsessed culture" is actually wrong.   It may be worse than that: youth obsessed and frankly delusional. They're not pretending to be young, they actually believe they are young. A "residual self image" in a person's mind of who he thinks he is, despite that image being 20 years younger. They picked an identity not supported by the facts. And has set up a media apparatus to reinforce the delusion, hide the reality.

So the actual young get squeezed out of their own demographic, into being even younger, or jumping over and becoming too old, too quick. If the kid is parentified, or grossly immature, you may want to consider that.

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===== ====== ===== The Last Psychiatrist: If You Want The Closest Thing To A Financial Disaster, Look To Etrade: How To Be Up 50% And Still Lose Everything
This is how I know we're entering a recession.

Etrade, ostensibly an electronic brokerage, also has a huge business as a bank-- and mortgage lender. To the tune of $42 billion. Which is at risk, a la Countrywide.

A Citigroup analyst downgraded Etrade, saying that there was a chance it could go bankrupt. It's not just the mortgages that are the problem, he explains, but nervous high net worth investors could pull their money "just in case," precipitating a further run on the bank and thus its eventual collapse. Anyone who has seen "It's a Wonderful Life" knows that the run on the bank is what implodes a bank, not something intrinsic to the bank.

And that's what has happened, is happening. No one wants to be the last one left. No one wants to be the hero and brave it out-- not to the tune of hundreds of thousands of dollars they could lose through no fault of their own. You couldn't get through on the telephone. People wanted out, or at least reassurance.

But let me be explicit about the cause. Etrade doesn't go out of business because the business failed; Etrade goes out of business because this guy said Etrade could go out of business. He even said it was only a 15% chance, but that's not what people heard. What they heard was, "fire!"

Let me also be clear about this: he's not wrong about Etrade. He causes himself to be right. Do you understand? Fundamentals don't matter here, only psychology.

You say: what do I care about Etrade? I say: If Etrade collapses, your chance of a recession is 100%. Depression becomes a possibility.

Here's why. If you default on your Countrywide mortgage, you lose your house, and Countrywide goes out of business. You lose money that you needed but that you never really had; you lose expected money. But if Etrade goes bankrupt, you could lose all your money even though you might be up 50% for the year.

First, the immediate impact of all losing that money means consumer spending falls gigantically. And that affects all the businesses one would have spent money at. Cancel Christmas.

Second, you will not be investing. Asset prices fall when demand dries up. Don't believe me? You think the selling yesterday was related to problems in Iraq? It was Etrade customers, trying to liquidate their portfolios and get out. And maybe some Ameritrade customers-- just in case, even though they had no problem. Etc. That's why the stocks that fell were momentum names with large price tags-- people wanted cash.

Third, for the long term, you will be that much more wary about putting money in a "small" ($400billion?) brokerage. Retail investor stops investing. Want to know what that looks like? Hit up a chart from 2000.

But aren't these deposits government insured? No, and that's why this is so huge. About $15 billion of Etrade's deposits are over $100k-- the FDIC limit. So they guy who has $500k there will only get $100k back (after a long protracted struggle with the government.) That money vanishes, and it vanishes, unfortunately, from the pockets of the very people keeping the economy from evaporating. It's bad enough when the poor have cut back spending; if the rich cut back, the economy's finished.(1)

And this is how I know it won't happen.

An Etrade bankruptcy is so powerfully damaging to the our psychology of economics that it would devastate our already tenuous situation. It's also why I know we're in deflation, not inflation. When you liquidate your assets and pull them to cash-- for whatever reason-- you are pushing up the value of the dollar. You are not spending as much because you're not even sure how much you have anymore. I know prices are rising, but wages aren't. Prices could triple, if you're not spending it's irrelevant. Hoarding or not spending or not having ends up being the same force on the economy.

Deflation. On worry alone. If Etrade actually goes bankrupt-....

So the government has no choice but to bail Etrade out. For the mental health of the economy, Etrade cannot die. Either the Fed will cut rates soon, or we'll hear a message from the Treasury. This isn't what I want or don't want, this is a bigger issue.

Jay-Z called the bottom in the dollar. I call a bottom in Etrade, here, because I can't believe the government would let it happen. So much, psychologically, is at stake.

Buying the stock here is a huge gamble, and I don't recommend it to anyone, but I figure if they don't save Etrade, it won't really matter how much I lose today anyway.

(long Etrade, and long the government-- for now.)

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===== ====== ===== The Last Psychiatrist: I Go To Germany For A Week, And The Country Implodes

And by implodes, I mean that the government herds us into recession and into psych clinics.

Today Secretary Paulson says he doesn't want to rush into more rate cuts-- or any economic stimulus. "Thoughtful" and "patience."

I guess surgeons can be thoughtful and patient, too, when they're doing, say, breast augmentation. But when the spleen and the pancreas both have grenade fragments in them, well, get cutting, Doc.

On November 13, I wrote that because the risk of mortgage companies and banks going bankrupt was so high, that it was therefore inconceivable the Fed would allow it to happen.

It's confidence. If (for example) Etrade collapses, faith in such institutions-- in stocks, in investing, etc-- also collapses. So you get a recession on worry alone, not even counting the actual money that evaporates.

I figured there was no way the Fed would allow that to happen, that they would pull out all the stops, risk inflation next year, risk everything just to prevent recession now. If nothing else, it's an election year.

I even bought Etrade stock in a "put my money where my mouth is" stand. I wasn't buying Etrade, I was buying faith in the U.S. economy.

Well, I was wrong.   Etrade's stock has fallen 40%, even after Citadel gave it $2.5B, temporarily boosting the stock price. And Citigroup is down 30% even after The Prince gave it $8 billion. And Warren Buffett and Bank of America gave Countrywide $3 billion, and it is almost certainly going to be bankrupt soon.

I can be wrong, what the hell do I know. But Warren Buffett?

On Friday it was announced that the unemployment jumped from 4.7% to 5%. About 50k less jobs were made in December than were expected. That sent the markets down, down. But then exactly the wrong thing happened.

Bush held a press conference after meeting with his "Working Group on Financial Markets." Instead of saying the obvious, such as, "Holy Crap! What the hell is happening! People are losing first their houses, now their jobs! Holy mother of God!!" what he said was, "the fundamentals of our economy are strong." He said that in September, too. And the markets-- the thing he was meeting about-- all collectively went, "Holy Crap! What the hell is happening! People are losing first their houses, now their jobs! Holy mother of God!!"

Even worse, there is a not preposterous interpretation of Fed-speak that suggests there won't be big rate cuts soon, but actually rate increases. And now Paulson, today.

You may not care about this stuff, feeling that it is removed from your daily lives, but I assure you nothing matters more. Unless you are in the healthcare, law, or defense business, you're in for a special kind of recession: it won't affect the very rich, they have buffers; it won't affect the very poor, they have nothing; but it will kill the middle class. And middle class can be simply defined as anyone who has a job they need.

Look, it's not surprising that Obama won the Iowa caucuses, in that either he or Hillary would have been believable winners. But for the Republicans to pick Huckabee-- that's middle class Republicans-- it's telling you that they're scared.

If you want a tie in to psychiatry-- and wealth creation-- here's what you do to become a millionaire in a year: go to a small city-town, something like Pensacola, Albany, Mobile, etc-- somewhere where most people are employed by a key industry (manufacturing plant, office park, etc); or to a Hispanic-heavy area (construction workers/contractors)-- and set up a psychiatric clinic. Hire a psychiatrist, three or four bachelor's level therapists, and wait. As the businesses close or cut back, and as construction ceases, volumes of people will flow in, miserable and in need of Medicaid and SSI or SSD.   And here is also your semiotic tie-in: all those people who were previously "contractors" or "homeowners" will suddenly be "psychiatric patients."

Because that is what we have. We obviously don't have a sound economic policy; and the country isn't designed to offer aggressive social services. So the default mechanism for dealing with poverty in our country is to herd them into psychiatry, with its legend of the Chemical Imbalance, promise of treatments independent of environment, and, of course, the opportunity to apply for SSI.

Medicaid pays about $30 med visit, $100 per therapy hour, every week. That's $430/month per "patient."   Hop to it.

The other thing you can do is stand outside of the homes that will soon be for sale-- try Florida or Inland Empire-- hold up $300, and wait for one of them to trade their house for the plane fare out of there.

The 2004 election was a referendum on Iraq. 2008 will be a referendum on your total debt. Believe it.

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===== ====== ===== The Last Psychiatrist: Illusionist

"i agree"

I.

The brain assumes that any two lines which meet must form a plane; specifically, that they do not overlap but separated along a third access by empty space.

But what makes the object an illusion isn't that the lines don't meet-- they do; but that the surfaces-- middle "prong" (starting from the tip and moving back towards the base)-- don't meet. In fact, the surface disappears. The illusion, therefore, is one of constancy: in a static 2D drawing, an object cannot disappear into nothingness.

The parts of the object are perfectly ordinary-- consider the tips vs. the base-- but their union presents a paradox because a static depiction demands change. It asks you to see the prong as both prong and empty space-- that it changes before your eyes. A surface becomes a boundary, and a boundary becomes a surface. It is as if the fork exists in two simultaneous states, an idea which is incompatible with our reality.

II.

"It's an illusion. It's an impossible object."

How is it an illusion? How is it impossible? It's completely possible, I'll draw it myself:

So real is this object that I could teach a blind man to draw it. How can you say it doesn't exist?

The illusion isn't that this 3D object doesn't exist. The illusion is that this object represents a 3D object at all, and that that 3D object doesn't exist. But the 2D drawing certainly exists, and the 2D object is not telling you to see it as a 3D object, the object isn't talking to you. The question you should be asking yourself is why you need to see this as 3D.   No sane person looks at this 2D drawing and says it is impossible:

The fork isn't an optical illusion at all; the eye sees perfectly clearly what is before it. This is a cognitive illusion; and, indeed, it isn't even an illusion-- your cognition parses every detail, analytically, interprets the discontinuities as part of a continuum. In short, the cognition knows fully well that what it sees is easily drawn in 2D and impossible to construct in 3D, and knows precisely where the error lies-- and yet it wants wants to see this object-- not any 2D objects, not a scribble ball, but this specific object-- in 3D, despite its better judgment. This isn't involuntary; you can stop any time you want. You want to see this a certain way, and so you choose to do so.

You are being lied to, by yourself.

===== ====== ===== The Last Psychiatrist: I'm Building A Rape Tunnel

i'm trying something new

From Artlurker:

...THE RAPE TUNNEL has come under fire from Columbus-based feminist groups not to mention local law enforcement officials. The artist plans to place himself in a room, the only entrance or exit being a 22 ft long plywood tunnel constructed by Whitehurst [the artist] himself. Then he says that for the duration of the gallery's opening he will rape anyone who travels through the tunnel into that room.
Why is he doing it? For effect:

Why rape?
Because as an artistic gesture, it's one of the most impactful I can think of... It dawned on me that if the work [we local artists] created had never existed, the world would be no different than if it had. None of it mattered to anyone outside of our small and insignificant circle of peers. I wanted something that would have more impact.

...I want to make it clear that I plan to make the experience as unpleasant as I possibly can to anyone who dares to crawl through the tunnel. I will try to the best of my ability to make them regret their decision.

...I'll try my very best to sexually assault him or her. The tunnel is constructed in such a way that it gets smaller the closer you get to the project room. The bigger you are, the more difficult it is to comfortably crawl out. And trust me, I have a lot of secrets up my sleeve to ensure that I can overpower anyone that comes through the tunnel.

We can have a discussion on whether this guy is a narcissist, a douchebag, a genius, or an idiot.

We can have a whole discussion on what should be the role of art; whether aesthetics exist independent of our consciousness or only because of its interaction with it; what constitutes art. We can discuss whether Warhol was an innovator by giving the artist the godlike power to decide what things are; since I'm an artist therefore this is art, and it can only be discussed as art-- you would no sooner describe War And Peace as "savory with a hint of paprika--" and in this way, The Rape Tunnel must be judged and described only as art and not as a legal or ethical matter;

or, whether Warhol was a hack who learned the wrong lessons from Marcel "is everyone here a moron?" Duchamp, in which case the Rape Tunnel, its artist, and anyone who goes to see it should be rounded up and sent to the spice mines.

So you can have those discussions: here, here, here, or here. I'm, however, going to discuss something else.

II. One Third Of Respondents Took It Personally

I don't remember where I read this statistic, but it seemed intuitively obvious: 9/10 participants find gang rape pleasurable.

The Rape Tunnel is a hoax; the "art" isn't the tunnel but the story about the (nonexistent) tunnel. The impact is in the (plentiful) discussion about it. Bravo. Score one for trolling.

But if the purpose of the art is the reaction, then the reaction is, in one third of the comments, hate:

Someone should turn this into the Self Defense Tunnel and shoot this asshole in the fucking face
I suspect (hope) someone will go in there with a lead pipe and crack his head open as he makes his move.
Someone please, for the sake of art and humanity, burn this down with him in it.
You have concealed carry there, right? Mr. Whitehurst, meet my friend Mr. Glock. Problem solved.
I'll be sure to pack my gloc-9 before checking out this exhibit.
People who did not have a weapon brought black men:

Probably not real, but if it is we should get someone like Mike Tyson who is tough, mean and has an attitude to go down the tunnel. After Mike beats his ass and bites his ears off, he'll BE art.
I will be there and i'm big and black
EYEM COMIN WII SEA WHO GOES MID evil You clownie Girl (by "Always Were Black")

References to raping him were not unexpected:

It would be quite interesting if someone with HIV decided to take a small trip through the tunnel.
Are there any large, strong, gay men willing to stop by and just pound this guy a new asshole in his little tunnel? Ya know, for the sake of ART? What a douche. Art fag.
if Dick Whitehurst is looking for impact, why not send a large convicted male rapist with a long history of brutally abusing cellmates in there with him. i can't imagine a more appropriate happy ending...
I think that someone with AIDS should stroll down that tunnel and give that loser HIV baby! and then when he's done raping you, say... "I have AIDS, and now you do too! Put that in your pipe and smoke it dirtbag!"
I just hope someone with AIDS goes in with a bloody diseased anus, gets raped and then asks him how he loves his new AIDS
though some creativity was displayed:

he said he'd do anything that comes in-- why don't we send in like random attacking animals like cobras, badgers, porcupines
two words: Chuck Norris

I'm specifically interested in the third or so people who expressed these sentiments. Why so much hostility? First, you don't have to go in. More importantly, why is this level of anger not directed at actual rapists? Years ago I lived near 180 and Broadway in NYC. That's a Rape Tunnel. If you go there there will be a guy waiting to rape you, sometimes they change shifts but there's always someone on duty. And they're hiring. Go there, get raped. EOM.

But no one is taking the A train north to kill that guy. In fact, you've basically accepted his existence, you've ceded that entire neighborhood to him. You don't like him, of course, but you don't hate him, you just put him out of your mind, you put that entire area out of your mind. Meanwhile, this artist, an ordinary man, who is only raping volunteers, who has not actually raped anyone-- that guy needs AIDS.

"But this guy is a douchebag/evil/narcissistic/idiotic--" And the guy on Broadway isn't? He's raping because he doesn't have healthcare?

"But he's trying to pretend rape is art!" So the crime of impersonating art is worse than actual rape?

etc.

All arguments about rape fail. You don't hate him because he's a rapist, you hate him because he isn't a rapist, he doesn't seem to know he isn't a rapist, and is going to rape anyway.

III. I Just Made You Hate 9 Gang Rapists

Cyril Connolly said, "Hate is the consequence of fear; we fear something before we hate it." He's wrong.

There are no special insights available about the nature of anger; but the nature of rage is well described. If you're willing to agree that the above sentiments are rage-- the irrational, out of proportion blinding hate that anyone else observing it thinks is pretty nutty-- then there's plenty to learn from it.

First, the rage comes because this guy is weaker than us. When we feel safe, when we're not afraid (of him), we're free to explode in rage. (That's why there's road rage and not elevator rage.)

In every horror movie I have ever watched, no one, neither characters nor audience, hated the killer. They're too afraid to hate. In fact, sometimes they side with the killer-- think of an audience of teen boys laughing at the funny/horrifying way the victim was butchered. (And, in reverse: only when they start to hate, when they feel the rage, do they become powerful enough to kill the killer.)

Fear assumes limitless possibilities: the thing you fear has infinite power, infinite resources, infinite resolve, unknown identity. Hate comes when you know them. Cyril Connolly did not say, "if it bleeds, we can kill it." But he should have.

IV. All rage is the result of a narcissistic injury.

I have no evidence, but I'll wager that none of the quoted commentors own guns, are black, or have ever raped anyone. I'll speculate but not wager they've never been in a tunnel before, either.

All rage comes from a narcissistic injury. So the question, "why are these guys so angry?" should be reframed: "what is it about the artist/the scenario that is a threat to their identity?" They're emphatically not afraid of being raped because they don't have to go to the Tunnel. They are only responding to the artist's words. That's the threat.

The reason you do not fear this artist and the reason you hate him is because you about him. You know how he talks, thinks, that he's an artist, etc. You may make incorrect judgments based on this information (e.g all artists are wimps) but it is that you created a coherent picture of him that is relevant.

The man on 180/Broadway whom you don't know at all is "a rapist," he has a right to that identity and you're not messing with it.

This artist isn't a rapist, he has no right to self-identify. How is he allowed to give himself so much power? You can't do it, you couldn't grasp that kind of power, you couldn't be "a rapist," because you're not that kind of person.

But he wasn't either.

V. How To Rape Everyone At Once

There's a lesson here.

If you're running, say, a newspaper, and want the population to fear someone, you focus on identity and offer no other details not consistent with that identity; you fix the identity as primary. You don't describe him, you declare him.

To make people hate someone, start from fear but then attack the identity. Offer otherwise irrelevant information that puts them not in a negative light-- too obvious-- but in a contrasting light.

To everyone else not intent on destroying our civilization to sell copies, there's this advice:

When you find yourself hating someone (who did not directly hurt you) with blinding rage, know for certain that it is not the person you hate at all, but rather something about them that threatens your identity. Find that thing. This single piece of advice can turn your life around, I guarantee it.

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===== ====== ===== The Last Psychiatrist: Imitrex (sumatriptan) Is Good For Many Headaches-- And Therefore Dangerous

In researching something else, I learned that Imitrex may actually treat the headache associated with subarachnoid hemorrhage-- which is a bad thing, because you're still going to die.
Subarachnoid hemorrhage, the "worst headache of your life"-- comes on suddenly, lasts for hours (even days, yes, days), worse in light or with sounds, but not affected by movement-- is the result of an aneurysm (usually middle cerebral artery) popping. CT is positive in 95% of cases if taken early-- the longer time passes, the less sensitive CT becomes.
A case report of a woman whose headache improved with Imitrex (6mg SQ) but still ultimately died. The authors said this was the only case report they found, but in the same issue is another such case report (improved after 6mg SQ and died later that day) , and a year later some British guys reported three other migraine patients who came in with undiagnosed SAH and their headache got better after getting Imitrex. (Two got 6mg, the other got 3x100mg). They were correctly diagnosed only after they came back with headache and meningeal signs, and got CTs.
The editor of the first journal notes that sumatriptan is not "migraine-specific" and is effective in treating other head pains (such as viral meningitis, and, I discovered, orgasm headaches *.) The authors of the earlier SAH report hypothesize that since triptans block transmission at the trigeminal nucleus caudalis, any pain from the meninges should be blocked. (In bacterial meningitis, the pain relief may also be augmented by the 5HT1D and B agonism, which (in mice) reduces inflammation, decreases intracranial pressure, and reduces white blood cells in the CSF(!)) This may be only true in acute meningitis, as failure in two meningitis patients may have been the result of sensitization of the caudalis neurons (where triptans are supopsed to block input) and spontanueous activity. (So get your triptans early.)
The obvious message here, given the efficacy iin SAH with such low doses of Imitrex, is that one should not assume efficacy is diagnostic of a migraine. Triptans seem to be efficacious across a variety of trigeminal neuropathies; which, like everything else in medicine, is good and bad.
----

* Orgasm headache: apparently triptans can treat or prevent "orgasmic headaches." The funniest line is in the abstract of that paper: "In patients who chose to predict their sexual activity, short-term prophylaxis with oral triptans 30 min before sexual activity might be a therapeutic option.."

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===== ====== ===== The Last Psychiatrist: I'm Not The One You Should Be Worried About

the poor girl in this Acura commercial never stood a chance

I.

I'm thankful to those who defend me, and I'm not surprised by those who hate me, but either way you are missing the point.   I don't matter. It's debatable whether my ideas matter, but for sure they matter much more than I do.

I am "Alone." What does that mean? It means that no other characteristic should matter to you, the reader, except that there's only me, whatever that is.

I don't write anonymously because I want to protect my career-- most of my work is forensic and it's unlikely the guy whose been in jail for a year awaiting trial for drug possession is going to care about my thoughts on DWTS; he's got way bigger problems, like how the city criminal justice system isn't merely unfair but quite likely completely unconstitutional. And I'll say, on my behalf, at least he has someone like me on his side.

I write anonymously so that you aren't distracted by my age or lack of manners or political sympathies. They don't matter. If you want to say that narcissism didn't play the crucial part in this maniac's murder of his daughter just because she liked the wrong kind of guy, then we can have a good rumble. But if you want to say that narcissism didn't play the crucial role because-- I'm white, or single, or drunk; then you're trapped in the generational circuit of illogicity that is the very point of this blog.

II.

I don't blame you for wanting to attack or defend me; that's how we're trained to think about complicated issues. We're alive in a time where the President's attackers and defenders both assume he is lying, saying "what he has to say." We don't believe words, we believe identity. If Obama did it, then it's either definitely good or bad, depending on what you think of him. Never mind that if you look at what he's done, it looks almost the same as what Bush did. Wild. Should've swallowed the red pill.

The Matrix is a great movie but a poor expression of Baudrillard's philosophy. The Matrix is quite straightforward, there's no confusion, no paradox: you're either in the Matrix, or you're in the real world. You may not know you're in the Matrix, but that doesn't change the fact that you are or are not in it.

A true Baudrillard Matrix would be a single world that became so fake that you no longer needed the original. The whole world becomes a fake; there is no recourse to the real world. You'll know it happened when you look at a copy of something, the original of which you have had no actual knowledge, and say, "oh, that's so authentic." If you are under 47 and think Mad Men is much more accurate about 1963 than Oliver Stone's JFK-- or vise versa-- then you're in the Matrix. GET OUT.

"Inability to participate in society," lamented Secretary of Socialism Wilkinson, eyeballs deep in the Matrix. That's what he thinks drives people crazy. He's right; but the solution isn't a redistribution of income, it's reducing the desire to participate in the Matrix. Somewhere in the past 50 years or so the media accidentally constructed an artificial reality that was hidden by the on-purpose entertainment reality of TV shows. You look at any of the CSI shows and think, "well, of course this isn't a real representation of actual crime scene investigators." But it never occurs to you to think as they're arresting a suspect, "since when did it become ordinary for professional cops in their 40s to have no kids, tons of disposable income, and regularly go out on dates that end in sex? And what the hell happened to body fat?"

No wonder people think-- feel, experience-- that they lose part of themselves when they have kids. Or grow old.

Commercials are even worse.   That attractive, well dressed woman who looks longingly at a passing two door Acura ZDX is a synthesis that you resist-- you know that they're selling Acuras, and you're not falling for it. You're so clever, seeing through it-- you know owning an Acura doesn't make you an attractive well dressed woman, nor will it attract such a woman.    But what you don't realize you're learning is that this is what attractive well dressed women look like. Acura is selling Macy's. And Macy's is having a sale; for the right price you can be 25 forever.

That advertising agency probably just wanted to sell some cars today; not change the society you will want to participate in tomorrow.

I guess that's why they say: May the best of your todays be the worst of your tomorrows.

But you ain't thinking that far ahead.

Know what I mean?

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: I'm One of The Best Doctors In America. Seriously.

Continuing my week long celebration of narcissism, let me jump on the wagon: I got an email informing me I was selected as one of the "Best Doctors in America." (5% of doctors, selected by peers; and no, I didn't pay them.) Yay!! Me!! Now...

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===== ====== ===== The Last Psychiatrist: Impulsivity In Kindergarten (Does Not) Predict Future Gambling
Here's how (not) to read a study.

Most people read this (Reuters):

Distracted kindergarteners [sic] become gamblers: study

or perhaps the actual study:

Results A 1-unit increase in kindergarten impulsivitycorresponded to a 25% increase in later self-reported childinvolvement in gambling (SE = .02). This was aboveand beyond potential child- and family-related confounds, includingparental gambling.

and ask critically, "well, I wonder how they define impulsivity?" or "are there other variables that could explain why distractiveness or impulsivity predict gambling?"

That's not where the money is: we can confidently assume psychiatrists have plenty of measures for impulsivity. The real question is whether psychiatrists know anything about gambling.

Typically, people question the causes of pathology; I want to know, what are they labeling as pathological nowadays?

So, I check:

cards; bingo; bought lottery, instant lottery(scratch and win), or sports lottery tickets; playedvideo games for money or video poker (eg, at arcades);and placed bets at sports venues with friends or on games thatrequire skill (eg, billiards, pool, bowling)

Let's all agree that this is precisely not at all what anybody thinks about when they think about gambling. You might say, "well, it still counts!" but it's hard to say you can predict X when everyone thinks X means something different from what you do.

Or another way of saying it: even if the results are accurate, why should we care what predicts playing?

The answer is, we shouldn't-- and neither do the authors.

II.

Psychiatrists, by which I mean residents, who actually spend any time reading journal articles often despair. They hit something like this:

The equation also controls for child (sex and early emotionallydistressed behavior) and family (maternal education and familydysfunction) factors. Our results bear on this fully controlledmodel: CGB_i6GR = a₁ + β₁ IMP_iKE + β₂PG_i6GR + ${gamma}$ ₁ CHILD_iKE + ${gamma}$ ₂ FAMILY_iKE + e_it,where a and e represent the intercept and stochastic error,respectively, CGB indicates sixth-grade gambling behavior (6GR),IMP indicates kindergarten impulsivity, KE indicates kindergartenentry, and PG indicates parental gambling involvement, for eachindividual i.

and succumb to self-doubt. "I don't know enough to interpret studies, I guess. How am I going to learn this stuff?" But while wondering if this study was a good one or not, something sneaky happens to them: the premise is absorbed, implicitly. They don't realize they've just been infected by a mind virus. "It's so hard to tell if this study really showed what we all know to be true...."

P values and ANOVA are red herrings.    The single most important question to ask when reading any scientific paper, ever, anywhere, is this question only, pay attention: what do the authors want to be true?

Nothing else matters. If you think there's a scientist somewhere publishing a paper that says, "son of a gun, I've devoted my life to this question and it turns out I've been wrong all along" you are beyond a crack pipe. Even if the research comes up negative, the scientist's thoughts inevitably turns to, "that study was flawed." The premise is never questioned.

Don't be fooled: "well, in our lab we looked at the serotonin receptor, and it didn't pan out. So we accepted that we were wrong, and changed focus to the dopamine receptor." Do I need to tell you that that is the exact same thing?

III.

The mistake is thinking the purpose of the study is the outcome of the study. The issue is not problem gambling, otherwise we would be limiting it to people with a gambling problem. The issue is not trying to predict which child will become a gambler. The issue is ADHD:

"Attention problems are a public health issue," she said.
That's what the study is about. The gambling is just another excuse to say ADHD needs treatment.

IV.

Once you ask the key question, you'll know exactly where to look for inanities. The Introduction is usually full of them.

Data suggest that in most cases, youthful recreational gamblingpredates pathological gambling in adulthood. (1,2,8,9)

The authors cite four studies for this premise. Usually, a reference means a primary source that has direct data about the issue.   I know without looking that none of those four references are that. I know this not because I know anything about gambling or pediatric studies, but because I know that if they're going to count bingo and bowling as gambling, they're not going to be too careful with their references in the Introduction. "But it's stuff everyone already knows." My point exactly.

NB: I'm not saying they knowingly pick non-supportive references. They absolutely think those references are supportive. They're caught in a self-reinforcing groupthink.

To illustrate my point, I looked up the four references. Only reference 9 had direct data on how many adult gamblers started as kids. The other three references (1,2,8) were about related issues (e.g. psychiatric comorbidities in gambling). They simply asserted the child-adult link in their respective Introductions. They, too, referenced their assertions: references 2 and 8 both used the same other reference to support that claim-- reference 9! Reference 1 and 2 both cited the same author, who wrote in two different venues.

Reference 9 found that 20-30% of adult pathological gamblers began "wagering" before age 15, as defined by 10 types of gambling, including "stockmarket, sports, and games of skill." Not only is this not really the definition the average person uses for gambling, it also isn't the definition used in this kindergarten study.

V.

I want to emphasize that studies are never about discovery, they are about confirmation. Researchers already know what they want to find. This is why I have long argued that financial biases in research are trivial, if for no other reason than they are obvious. Ideological bias, institutional bias, personal bias-- these are far more difficult to detect. There's no disclosure for them. They matter much more. If a researcher's son is on Depakote, how will he interpret a study he does that finds Depakote doesn't work? Would it really matter at all whether Abbott paid him or not?

None of this means that research is corrupt, or that it isn't valuable.   But it does mean that you can't accept conclusions as written, and the Discussion section is basically an op-ed.

Nothing wrong with that either, except that everyone thinks it's journalism.

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===== ====== ===== The Last Psychiatrist: Inception Explanation

that's as good an explanation as any

(There are a number of sites which offer a scene by scene explanation. But this one is better. Here there be spoilers.   Also, see: The Ultimate Explanation Of Inception.)

Was it all a dream?

Inception cannot be interpreted in a vacuum. It draws from our collective unconscious, which is depicted by other movies.

It is impossible not to compare Inception to The Matrix, and Nolan, eyeballs deep in post-modernism, must know this. He actually begs us to to make the comparisons-- Ariadne touching the mirror (which, rather than passing through it, she shatters); the tailored clothes ("residual self image"), the gravity defying fight scenes; the bullet time explosions. I doubt these are gratuitous or even an homage, he's responding to the Matrix using Matrix language, which is ultimately our language since we the language of media. And his response-- the same one in Memento and, The Dark Knight, is that what you do, not what you think, defines you.

The Matrix was a straightforward, though awesome, story of narcissism; a single man for whom reality is incidental to ego, who defines himself not on what he does (initially, he does nothing except hack computers) but who he thinks he is. He is the main character in his own movie-- maybe not the best, not the strongest, but the main one. Everyone else is supporting cast. All he needs is the right cluster of magical (think like a 2 year old) events and the awesomeness that he knows is inside him will become real. Note also that everyone is perfectly content being the supporting cast. Everything they think or do is about and for him.

Inception is the exact opposite. It doesn't matter whether you think it's all a dream, or just some of it, or it's actually someone else's dream, or it's all real. The main point-- and Nolan makes it twice-- is that you can't hide from yourself.

Second main character Fisher could choose to coast, identity handed to him by his father-- pretend he is who everyone says he is-- but he wouldn't have actually done anything himself. He would be the person who hasn't done things, but everyone still thinks he has. His only choice is to grow up, find his own way, define himself.

Cobb-- a former Architect-- can dream anything he wants; his wife begs him to stay with him, and many characters admit that ten years or a lifetime in a dream is just as good as real-- "who's to say?"

But though Cobb can do that, it's still no solace because it doesn't work. No matter what world he picks, the guilt follows him, the guilt defines him. Cobb can't pretend to be anyone, he can't hope to become anyone, and not clothes or guns or drugs or genetics or hypnosis or even being in someone else's dreams will change who he is.

It's almost impossible, in real life, for any of us to understand how a single emotion can be so defining; it's the stuff of movies, and we prefer to define ourselves rather than wait for events to shape us. Usually, movies try to make that defining emotion love, but that fails because it's idealized love that doesn't take into account that there is someone else on the other side who has their own ideas about love. Nolan doesn't go that way-- this isn't a love story. Nolan chooses (twice) death. When someone very close to you is abruptly, unexpectedly, incorrectly taken from you, everything else is contaminated by that.

The death of a parent is different because it is never completely unexpected (unless you're a child) and it is understood to be something to overcome by moving forward. Fisher succeeds. But there is no forward when your child or your spouse dies. The only way forwards is downwards.

If you've not lost such a person, you wouldn't know that every morning before you open your eyes, you spend a moment trying to change reality: I am going to wake up, and everything will turn out to have been a dream. Cobb doesn't wait for morning to try this.

Did the top stop spinning? Probably not-- it spins a very long time, given that it started well before the camera fixed on it. But that's totally beside the point: the audience was rooting for it to stop. We have an instinctive aversion to other people's false realities because they aren't our realities.

Cobb doesn't bother to check the top at the end because it doesn't matter whether he is dreaming or not. No matter what, he's the same person that the same things happened to. Nothing else is real.

-------

These are just random thoughts I had about the movie, feel free to add or correct them; I'd like to write something better about this movie when I have thought about it more.

Totems are for people to project their ambivalence (e.g. hate) about others.
Magical thinking is the "omnipotence of thought"-- that your thoughts can alter the world
Last line of Totem and Taboo: In the beginning was the deed.
Ariadne = the woman who helped Theseus navigate the minotaur's labyrinth (ball of red thread-- follow Saito's blood trail); Ariadne was eventually abandoned by Theseus-- left sleeping on the beach at Naxos. Didn't Ariadne and Arthur share a kiss, and later wind up on the beach?

Ariadne's totem/token was a PAWN; Arthur's was a loaded dice.
All dreams are always wish-fulfillments.

Matrix references abound; "you have to dream bigger" (of a bigger gun); the fights, defying gravity. Perfectly tailored suits, hair-- "residual self image?" Signals the dream world?
Totems, like tattoos (Memento)--- physical reminders of reality
Architect = Revolutions?

If it's a dream, who is "watching" the top spinning all by itself?

Suits also call up the old aesthetic that so many post-modern films have (Dark City, the Matrix, The Thirteenth Floor, etc.)
Leads to "Eames" (the forger)-- likely Charles Eames, the modernist designer and ARCHITECT who also made some experimetnal films... like 1969's "Tops. "Tops are born, they live, and then they die."

First scene with Mal (= "mal")-- he ties a rope to her chair to hold him as he goes out the window, but the chair slips empty-- she is not his anchor.
Fisher is the audience, the mark. We/he need to have an idea incepted, we need to experience the drama, the dream, and the catharsis.
Each level of the movie was a different kind of film: The kidnapping is a thriller, the hotel is a heist, and the mountaintop was an action film. Each also had different hues: first Saito meeting was red/yellow, kidnapping=blue, hotel/heist=brown, mountaintop=white. Think Matrix reality=brown, in the Matrix=green

Were all the totems game pieces? pawn, poker chip, top, loaded die. Why?
This movie can also be seen a a metaphor for movies. Cobb is the director, Eames is the actor, Arthur the producer, Ariadne is the writer.
You can tell a dream because you can't remember how you got there; much like scenes in a movie, which either have an establishing shot (e.g. a wide shot of a building where the scene will take place) but Inception noticeably lacks these establishing shots-- you're dropped right into action.
The top at the end is for us to see if it's a dream, not for him-- he doesn't even wait-- but the truth is that he's in a movie, not a dream, so complete is our suspension of disbelief.
Why is it called Inception? If they're doing the "opposite" of extractions, it should be Insertion.
Raskolnikov's guilt was over the murder of a PAWNbroker
There was a scene after dreaming that he runs to the bathroom to check the top, but he is interrupted. From that point on, all bets are off as to whether we are still in dreamworld.
MAl CObb is played by MArion COtillard, who also played Edith Piaf in "La Vie En Rose." Edith Piaf is the singer in the song played on headphones to time the wake up ("Je ne regrette rien.")
The top is Mal's totem, not his. His totem is his wedding ring.

---

A more complete explanation can be found here: The Ultimate Explanation Of Inception.

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===== ====== ===== The Last Psychiatrist: Infidelity And Other Taboos, Media Style

Freud was a punk

The story that is making the internet and morning TV rounds:

Two people, a man who looks suspiciously like Julian Assange, and a TV reporter who looks exactly like every MILF porn actress working today, divorce their spouses and get married.

The original couples were friends, and the two met at their kids' elementary school. There are five kids between them, and, you know, whatever.

The twist is that they announced their marriage in the Style section of the New York Times, because, of course, they hooked up in style. The further twist is that they semi-shamelessly recount in the Times how they fell in love while they were still married to other people.

Carol Anne Riddell and John Partilla met in 2006 in a pre-kindergarten classroom. They both had children attending the same Upper West Side school. They also both had spouses. ... The connection was immediate, but platonic. In fact, as they became friends so did their spouses. There were dinners, Christmas parties and even family vacations together.

Hardly uncommon; hardly newsworthy, but a little-- brazen?-- to reveal you were basically cheating. Why even mention all that about the school and the spouses? Why not simply say "we met and fell in love?" Or better yet, why not just say nothing? And why would the NYT report this?

The story inspired the predictable controversy with the obvious positions:

"The NYT's responsibility is to report, not be the judge."

"There's no infidelity-- they didn't have an affair, they split with their spouses before getting together."

"Cheat if you must, but don't try to parade it in public as a love affair..."

Whether what they did is wrong or modern is easy to answer (yes x 2) and not the point here. Nor is the point-- a good one nonetheless-- that by the running of the story, the New York Times reinforces its position as the one who decides things, in this case ethical things. You may be invited to offer comment, of course, but the best you can do is agree or disagree with the NYT-- they become the authority. The burden of proof falls to you to explain why they're wrong.

Nor is the point that these two dummies didn't anticipate that they'd be criticized. Were they really so brazen, so shameless, to think we'd all be "wow, that's so Lifetime Original Special!" Not exactly.

The mistake is in thinking they shouldn't have publicized their story. They didn't have any other choice.

It's a mantra: narcissists don't feel guilt, only shame. Well, it's not completely true, sometimes they do feel guilt, but you have to be hitting on a taboo to feel it.

Even the most hardened narcissist feels some passing guilt when their spouse is sobbing on the kitchen floor. How do you get over that? (Pills won't help, but psychiatry is happy to tell you they might.)

This is how narcissism eradicates guilt: it rewrites the story, or as the po-mo mofos say, "offer a competing narrative."

[Offers Ms. Riddell] We did this because we just wanted one honest account of how this happened for our sakes and for our kids' sakes.

One honest account? Which were the accounts that were not honest? Were there any other accounts at all? Oh, yeah, reality. Well that account doesn't count. This one's better:

it all changed two years later when Partilla invited her out for a drink at a local watering hole, the first time they had gotten together away from their spouses. "I've fallen in love with you," Riddell recalled Partilla as saying. She said she beat a path out of the bar, only to return five minutes later to tell him, "I feel the exact same way."

Dress it up in the language of a story, of overcoming, of finding a soul mate, of mid-life romance, of self-actualization. These two were fortunate enough to be able to make it an actual story-- in which they are the main characters and everyone else is supporting cast and the readers-- you-- will focus on the main characters. You may hate them, but that doesn't matter. What matters is that they are the main characters.   That turns guilt into shame, and if there's no shame

We are really proud of our family and proud of the way we handled the situation. There was nothing in the story to be ashamed of.

They win. That's how narcissism discharges guilt.

You'll notice that the exes are not mentioned by name or interviewed in the story; that's not to protect their identity, it's because the author of the article didn't care/need to interview them, because the author, and the new couple, are focused on the STORY. Win.

In other words, putting their otherwise quite shameful story in the NYT wasn't dumb, poor judgment, or even damaging to their reputations no matter how many people end up hating them. It was necessary to their own emotional survival. As long as you hate them for it, they don't have to hate themselves.

II.

I do not like the hypocrisy game, where you try to detect hypocrisy in someone as a proxy for dismissing their ideas; it is lazy and unhelpful, and usually done by those who themselves overvalue projected identity. But sometimes you can't help but play. Which brings me to this nut:

First, let's get the preliminaries cleared out of the way. A week ago, Sarah Palin was never going to be president of the United States. Today, Sarah Palin is never going to be president of the United States. Once you've accepted that fact (although it's not clear that Palin herself has), the political impact of this decision is minimal -- the Republicans as a party look even a little flakier than before (bad for the GOP, but what else is new?)

I don't expect journalists or anyone else to be free of moral ambiguity, but it should be a postulate that if you choose to write those words you should not also be having sex with your daughter. Allegedly.

David Epstein, HuffPo-Mo blogger and Columbia professor of Applied Po-Mo allegedly had a sexual relationship with his 24 year old daughter. I'll save you the google search: he doesn't have a mustache. I was surprised as well.

Many think his behavior is shameful. Harsh. Some think it is illegal, though clever people found Lawrence v. Texas on wikipedia and discovered "an emerging awareness that liberty gives substantial protection to adult persons in deciding how to conduct their private lives in matters pertaining to sex." After a nap they figured that might apply to incest as well. And why not? Consenting adults? It's a privacy issue, right?

Oh, it's a privacy issue, but not in the way Scalia meant. The goal isn't privacy, the goal is the reverse.

Dummy and his daughter allegedly sent text messages to each other, which anyone with a Nike shirt knows is what you want to do to get caught as quickly as possible. I'm not saying Epstein wanted to get caught (though I am thinking it), but when you break a taboo you either face the guilt Dostoyevsky style with a lonely nervous breakdown and a trip to redemptive Siberia or you get out a pen and rewrite the story. In Epstein's case, we're rewriting it for him: the mere discussion of this nonsense, the simple fact that any of us hate our fathers enough to write, "yes, but it's a legal issue..." means that Id and Ego fought Superego and Id and Ego won. He's taken private guilt and core dumped it to the internet for public judgment and the internet will always be more forgiving than he could ever be. As cocaine magnate Sigmund Freud wrote, "when the story goes live the guilt goes dead."

III.

The stats on second marriages and the psychology of vampires and vagina predict that Riddell and Partilla will stay married. When you hook up in the presence of adversity it tends to reinforce the relationship as they steel themselves against Those Who Just Don't Understand (though watch out, sometimes you find that that adversity was the only thing keeping you together). And it's not how I'd run my life, but they did it and there's no use yelling at them, they have to make it work for themselves and for the kids, so best of luck: bad start, hope you make it worth it.

But what you need to get out of these stories is how this generation and forwards will deal with guilt: externalizing it, converting it to shame, and then taking solace in the pockets of support that inevitably arise. Everyone is famous to 15 people, and that's just enough people to help you sleep at night.

It is, in effect, crowdsourcing the superego, and when that expression catches on remember where you first heard it. Then remember why you heard it. And then don't do it.

---

You might also enjoy:

How to get away with rape

Charlie Sheen Has An Awesome Experience

The Atlantic Recommends Abandoning Marriage

Don't Settle For The Man You Want

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: "Inflammable Means Flammable? What A Country!"

You're going to say that I made this up. I am not making this up. I wish I was, because then I could say,"stop making things up," and everything would be ok. But it really happened, and I can't stop things from really happening. So I drink.
This is the conversation I had with another psychiatrist. He is wearing a Ermenegildo Zegna suit. It fits him well.
I say, "... so if I have him [hypothetical bipolar depressed patient] on Depakote and Seroquel, once he's stable I try to reduce the dose, or even stop one of the medications."
He shakes his head. "I would never stop the mood stabilizer."
"Why-- wait, which one's the mood stabilizer?"
"The Depakote."
"But how do you know it wasn't the Seroquel? That's the problem with starting two drugs immediately, you don't know which one worked."
"Well, you need them both. Especially if you're adding an antidepressant."
"What antidepressant?"
"Seroquel."
"Seroquel's an antidepressant?"
"In this case it is, you're using it for bipolar depression."
I blink my eyes, to make sure I still can.
"Then what's the Depakote?"
"The Depakote is the mood stabilizer."
"But how do you know the mood stabilizer isn't the Seroquel?"
"The Seroquel is the antipsychotic."
A voice tells me to stab him.
"Why can't you just use the Seroquel-- the antipsychotic- slash- antidepressant-- alone as a first try? What benefit does the Depakote give you over the Seroquel?"
He says it slowly, enunciates, because he deduces that I don't speak English. "Because the Depakote is the mood stabilizer..."
He looks at me. I look at him. He is wearing a yellow Bolgheri tie. In my mind it is on fire.
"...Besides, if you use Seroquel off label like that, you'll get sued." Blaming lawyers, the last refuge of the incompetent. "And for what? Why take the risk?"
It's at this point I realize he's not wearing socks. "If you're going to use that logic, Depakote isn't indicated for mood stabilization, either."
He looks at me incredulously, then suddenly he realizes something. "Oh, okay, right, I see what you're saying now... but at least Depakote has FDA approval for Bipolar Disorder." QED. He's very happy now. I can't find the waiter. Why is my drink empty?
There's an uncomfortable pause. He wants to show me he's a skeptic, too, that he's carefully pondered these issues.
"I have a theory, have you ever used meclizine (a drug for vertigo) as a mood stabilizer?"
"No, I had never heard of that."
"I haven't tried it either, but it might make sense: meclizine stabilizes your balance, so perhaps it could stabilize your moods?"
I want to call the State Board of Medicine but realize I'm in a different state and I don't have the number in my phone. "I doubt the insurance companies would ever cover it."
He slowly, purposefully, nods his head. "Fucking meddling managed care."

I tell people all the time, don't get sick, don't ever get sick, but no one listens to me.

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===== ====== ===== The Last Psychiatrist: In Honor Of Columbus Day: Christopher Columbus Was Wrong
Repost.

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===== ====== ===== The Last Psychiatrist: In My Language

I don't know. As per Wired Magazine, this is real.

I look at this, and ask, would I have thought she was capable of this if I met her in passing? Would I have known it if I performed a psychiatric exam, but without tests?

Would I have misperceived some of the humming as psychosis? Which medications would I have started?

Everything I would have done-- wrong.

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===== ====== ===== The Last Psychiatrist: Intentionality In Treatment

the Abilify was supposed to improve your symptoms but you got better anyway

As a follow up to advice in psychiatry.

Intentionality in treatment matters, and it is conveyed in subtle ways.

In an experiment, a subject could be put through a electric shock experiment, or a auditory tone experiment, as chosen by a second subject. However, sometimes this choice was reversed by a computer, and the resultant switch was revealed to the subject. In other words, he would see on the computer "Subject B chose to give you tones; however, you will receive shocks."

In this way, Subject A would think Subject B intentionally gave him shocks, or unintentionally.

You can see that the subjects experienced the pain as more severe when they thought it was on purpose. However, look carefully, you see something else: when it's by accident, they got used to the pain. When it was on purpose, they didn't get used to it.

II.

Cognitive reframing can be used everywhere.

There are plenty of examples related to pain, but it's better if this can be applied more generally. When things are bad, is there a way to experience them as less bad? Instead of studying something as vague as "sadness" or "anxiety" let's look at something concrete: losing money.

When subjects were given $30 to gamble (max win $572, max loss $30) subjects were measured on how loss averse they were:

Then these same subjects were given a cognitive reframing: "pretend you are a trader" "think like a pro" etc.

This technique reduced loss aversion:

not just subjectively, but even as measured by skin conductance, which measures arousal and sympathetic nervous system activity (similar to lie detector):

Graph A shows that while people were more aroused (by skin conductance) to losses than to gains ("Attend" is simply gambling without using the reframing trick)-- when given the cognitive reframing (the "Regulate") this arousal disappeared. "Thinking like a trader" neutralized a physical response.

When you tease out the people who are good at reframing (Graph B, the "Regulators") the difference between using the reframing and not using it is even bigger.

Clearly some people are naturally good at this, and others are not; but the technique can be universally tried. The more you practice, the better you'll be.

III.

But the important part of this message is that a person's experience of anything is very much influenced by context, presentation.

Psychiatry has adopted a policy of pulling aside the curtain: letting the patient in on the language usually reserved for practitioners, which is fine, except that it is almost always misunderstood. "Dirty drug," "bipolar", "flip him into mania"-- "augment with Abilify"-- these terms convey information to the patient that is usually not intended-- not to mention being factually empty. They are never corrected, because the psychiatrist has forgotten how to speak in ordinary but still descriptive language.

Every university hospital has a "Treatment Resistant Depression" clinic. However, they are by referral only; a patient can't just call and make an appointment. So why name it that? It's a signal to doctors, "send them here." But it's not a secret signal-- the patient knows what it's called. What message does that send to the patient?

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Interest Rates and The Moral Hazard: Why You Must Buy GOOG Now

Here’s what’s happening in the stock market: people bought stocks on credit, and now they can’t pay it back because the interest rates are too high, and their collateral caught on fire. And the lenders want their money back, now.
This has everything to do with psychiatry.

The TV news keeps talking about subprime mortages—during the housing boom, people took mortgages, with no money down, at low introductory rates, and now these rates (ARMs) have increased, so their mortgage payments have increased. But the housing market has simultaneously fallen, a lot, so that the price of the house is often worth less than the whole mortgage. In other words, you’d be better off simply walking out the door and defaulting.
But what’s happening in the markets is about more than mortgages, it’s about credit. Partly from losses, but mostly out of fear, lenders are unwilling to offer the easy credit—or credit of any kind.

Typically, hedge funds borrow massively against capital. If a hedge fund has $X, they can borrow from banks 10X. As long as the market is stable, they can make the interest payments on that loan, just like you would for a credit card. But if the market goes down, not only can they not make the interest payments, but worse, the bank calls them up and asks for all its money back—at once. If the bank sees the market tanking, it will call in its loans—a margin call—because it suspects that every moment it waits is a greater chance of default. So the hedge fund has to raise money by selling things, or dipping into the initial capital. But what if the initial capital of $X was actually other people’s mortgages, which hedge funds bought as an investment—and are now nearly worthless? The answer is the old adage: when you can’t sell what you want, sell what you can. So they sell everything, and the market tanks uniformly. That’s why Google, which has nothing to do with mortgages and has no debt of its own, was off 70 points.

I know a lot of people don’t care about hedge funds, the bath houses of the super rich. And therein lies exactly the problem we are addressing today.

The average person’s assessment of all this is this: fuck ‘em. They were making easy money for too long, for nothing (defined here as capital; they simply borrowed the money to make more money). If they go bankrupt because the market takes a dive, too bad.

The problem is that credit isn’t just about hedge funds, or even mortgages. Without this credit, private equity firms, and hedge funds, don’t invest capital in languishing or dying companies. (Remember Dunkin’ Donuts 20 years ago vs. today?) If they don’t invest, the company goes bankrupt, and people lose their jobs. These people who lose their jobs don’t therefore spend their money on other products, so other companies lose profits (which is why, in these cases, food and household products stocks remain stable—you still gotta eat-- while auto, luxury goods, electronics- expensive, less necessary stuff—stocks go to the toilet. That’s a recession.)

So credit is necessary; and the only way to supply easier credit in these circumstances is for the Federal Reserve to lower the interest rates. Lower rates mean easier borrowing means everything can continue. And stocks go back up.

And, of course, hedge funds make billions, again.

So the balance the Fed has to strike is this: can they supply enough liquidity, e.g. make borrowing as cheap as possible—so that businesses can stay afloat, and mortgages can get refinanced and people can stay in their homes—but not send the message to hedge funds that every time something bad happens, the Fed’ll come in and save the day?

This is often called the Fed Put (or, properly, the Greenspan put or Bernanke put, named after the Fed chairmen.) A put is a trading instrument that reduces risk; it’s basically like buying insurance on your investments. If Bernanke routinely lowers rates whenever things get bad, then people will begin to anticipate that he will do it again. The consequence—wait for it, wait for it—is that people take on more risks. They know there’s a limit to their losses. Which is exactly the opposite of what the Fed wants—they’re lowering the rates because people took on too much risk (credit) in the first place, and lost.

This is called the Moral Hazard, and I capitalize it because it is to be revered. It defines humanity. Forget about psychiatry, forget about economics, human beings can be rigorously distinguished by their behavior vis a vis the Moral Hazard, and, even more rigorously than that, how they apply the Moral Hazard it to others.

Nothing, nothing, is more important than this concept. Let’s begin.
Next up: The Moral Hazard
disclosure: long GOOG; though I'm confident Warren Buffett will buy CFC and it goes to 30, I wouldn't buy that death trap now even if it came with two Raiders cheerleaders and a brick of platinum.

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===== ====== ===== The Last Psychiatrist: Internet Addiction Belongs In The DSM-V

Agreed. And then let's rename the DSM The Book of Fantastikal Magickal Pixies and incorporate it into the Monster Manual.   And let Mad Libs publish the assessment tools.

Jerald Block has an editorial in the American Journal of Psychiatry, in which he explains why he believes Internet Addiction should be considered a psychiatric disorder.

His reasons include the usual: excessive use, withdrawal (anger, irritability), tolerance (need for more or better), and negative impact on life.

The debate as to whether or not this belongs in the DSM or not entirely misses the most obvious point: no one is addicted to the internet. Ever.

Don't scoff. Let's log on together.

Let's say you are "addicted" to World of Warcraft. A new game comes out, called Universe of Ninja Piratesses, and you move over to that. Guess what? You weren't addicted to WoW or UoNP, but to multiplayer role playing games. You can follow this logic all the way out to: it wasn't the internet you were addicted to, but something else.

I don't have the data in front of me, but in a study I just made up 0% of porn website "abusers" were at least partially satiated when offered Marthastewart.com. Withdrawal symptoms were actually worsened. Three people punched their computers (two in the monitor, one in the graphics card.)

Ask a 20 year crack addict when was the last time they used powder cocaine. Do they miss it? Are they in withdrawal? "But crack is cocaine." No, it isn't, or else they would be using both, wouldn't they? "But crack is more potent and addictive." Then why don't cocaine adicts move over to crack?

Do you know how many Xanax addicts I've had throw back at me a prescription for Klonopin? It wasn't availability, I was giving it to them, they had it in their hands, and they refused it. In theory it should have been "good enough." It wasn't.

By age 25, every guy has been with a girl that-- sorry, let me start over--

By age 25, every guy that has been with a girl has been with a girl that they couldn't get enough of, couldn't live without, called all the time, left school work undone, called into work sick, code-named "Freebird" in a journal entry, etc, etc-- but the relationship sucked, this girl was so evil that all his friends wanted to hit him with a sack of doorknobs. Was he addicted to her? Technically, yes-- but really, no. More to the point: she wasn't actually evil, and he wasn't addicted to her, at all. (I mean, now that you're 40, you see that, right?)

"Yes, but there's a common addiction pathway..." Oh, I don't know. If this was true, chemical addicts would have generally substitutable addictions, and they don't. Experiments with mice strongly support the idea of substitution (e.g. cocaine addicted mice will thirstily self-administer amphetamine) but humans don't really do this. (1) And chemical addicts should also have very high rates of other (non-chemical) addictions as well, and they don't. (2)

These non-chemical, behavioral addictions are more properly labeled obsessions but-- and this is the point-- an obsession is not a disorder. Obsessions can cause harm, we can try to help people with them, but they are not themselves the problem, they are symptoms of something else.

That something else may not be a disorder, either: fragile self; guilt or shame; low or high self esteem; flawed but automatic assumptions, whatever-- but trying to "treat" internet addiction without addressing the underlying problem is like treating cancer with Tylenol. Not only does it not help, it actually makes the situation worse.

Dr. Block's intention was to describe a series of behaviors, not to create a new disease. He's already established believer in the positive power of the net, online games, etc. Unfortunately, psychiatrists will only see this editorial, and come to the wrong conclusions.

In the article he cites research from South Korea, where the average kid (supposedly) uses the internet 23 hours a week, and thus is at risk for addiction. Compare that to the U.S. 20 years ago, where the concern was 20+ hours of TV a week. I do not recall discussion about kids becoming addicted to TV; we worried they were becoming stupid. What's changed isn't the medium or the amount of time on it, or the harm to the intellect or society; what's changed is the social movement to pathologize, rather than condemn, behaviors.

I'm not saying let's go back to condemnation, but to put "Internet Addiction" into the DSM legitimizes the symptom-is-disease approach that has caused such great difficulty for patients, and nearly irreparable harm to humanity.

----

(1) Please do not say the words "dopamine" and "nucleus accumbens" anywhere near me, I still have my old sack of doorknobs. These explanations could not be more general and useless. Using those two in support of a common addiction pathway is like involving "gasoline" and "spoons" in the diathesis for serial rapes. Even though these are involved in various "addictions"-- cocaine, alcohol, internet, sex-- these "addictions" and their associated behaviors are so disparate that the pathway serves no useful clinical target. Haldol blocks dopamine in the nucleus accumbens, but you can't cure alcoholism with it, can you?

I'm not denying that such a pathway exists, I'm doubting the utility of this information, even if true. Call me when science catches up to your lies.

(2) Here's an example: why do so "sex addicts" or gamblers have such high rates of drug abuse, but the converse is not true?

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===== ====== ===== The Last Psychiatrist: Intrinsic Value of Money

A bird in the hand is worth two in the bush if that bush is a pricker bush. And only if people actually want birds, not bushes.

I.

The Economist describes a study in Psychonomic Bulletin and Review which people were given a regular dollar or a Susan B. Anthony dollar, and asked to estimate the cost of napkins, candy, etc.

People offered the banknote believed, on average, that they could use it to buy 83 paperclips, 72 napkins or 46 sweets. Those offered the coin thought 39 paperclips, 51 napkins or 27 sweets. In other words, the note was believed to be almost twice as valuable as the coin.

Similar results were obtained using two one-dollar bills vs. one two-dollar bill.

This shouldn't be surprising, however, when this exact (reverse) principle explains why casinos use chips, arcades use tokens-- and why credit card debt is so easy to get into.

The authors explain this to be a funcition of familiarity-- familiarity holds more value.

II.

But there's a little more to it.

The mistake is to interpret these results as indicating, e.g, the dollar bill above is believed to be able to buy 83 paperclips or 72 napkins, etc-- that the dollar bill is believed by people to have a certain value. False.

To prove this, ask someone how many paperclips would it take to buy 72 napkins? The answer should be 83. But most likely, they'll just look at you blankly. They have no idea what the exchange rate is. Notice how with the Susan B dollar, opposite to the paper dollar, paperclips were worth less than the napkins.

There's a difference between use value and exchange value. Napkins and paperclips have considerable use value that you feel, instinctively, but nearly no exchange value (i.e. you don't trade them for other stuff.) Money is the exact opposite. Trying to convert exchange value for use value in a back and forth line is hard enough; trying to do it in a triangle with three objects is nearly impossible.

Marx had hoped that the use value of an object would be the amount of labor embodied in it, but of course that is even intuitively wrong. The use value of the napkin has absolutely no relationship whatsoever to its labor content; if the labor to make paperclips increased, the napkin holder would have no way of quantifying it to alter the exchange value. Because he doesn't care how much labor went into it. Use value is entirely subjective.

Consider the commoditization of money (currency.) Many people devalue the penny (e.g. throw it in the trash,) even though some argument can be made that the copper alone is worth keeping. Labor theory would make the intrinsic value of a penny higher than a nickel. (cost of copper is higher, but labor to make coins is mostly the same.)   But yet, it's tossed.

Or, the reverse case with quarters.   You may have a dollar, but you'd very likely trade that dollar for three quarters if you needed to fill a parking meter. The quarter itself suddenly has value beyond its denomination, and you may value it anywhere from $.25 to $2.00, depending on the circumstance. The reason is this: the value of not having a quarter is 100x, or $25-- the cost of a parking ticket.

This value is not transitory; to any regular city parker, the quarter almost always carries more value than $.25, even though-- and this is precisely the point-- the higher value of the quarter cannot be reflected in the economy at all, ever. Try buying a $1 coffee with the three quarters you just traded for a dollar.

The price of oil, $118, in the face of falling refinery output and comparatively calm international relations, suggests that the price of oil has less to do with demand or supply, and more to do with something else-- in this case, the falling dollar.

If you do not grasp this, if you do not feel this in your bones, you will always be a wage-slave.   It is absolutely no different than picking a spouse, who I am sure you feel is the perfect mate for you, while another person scratches their head and says, "what the hell does that nut see in that other nut?" The key to making money is not working harder, or smarter, or investing, or anything else. The simple, one koan key is to understand that things have different values simultaneously, to different people.

And I hope it is clear that this doesn't apply only to money.

But anyone who understands this has the ability to exploit this.   Ultimately, you get to choose who you are. Choose.

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===== ====== ===== The Last Psychiatrist: Is A Brain Glitch To Blame For Financial Crisis?
Yes, but not that one.

CNN reports on a study:

"the real cause of the financial crisis could actually be down to a quirk of the human brain."

Take a moment a speculate on what you think that glitch might be. Nope:

According to a new neurological study by Atlanta's Emory University, expert financial guidance causes the brain to switch off, disengaging from its usual rational decision-making process.
"It's almost as if the brain stops trying to make a decision on its own," Professor Gregory Berns, who led the research, told CNN.
"Normally, the human brain uses a specific set of regions to figure out the trade-offs between risk and reward, but when an 'expert' offers advice on how to make these decisions, we found that activity in these regions decreases."
Why would it be surprising to him that we trust experts?

I.

The study doesn't just find what brain regions are involved in decision making, it even quantifies the effect of expert advice on a person's choice. But as good as the study is, the interpretation is flawed. The brain glitch isn't that we trust experts. The real brain glitch is the one that made him put scare quotes around the word "expert."

"Our brains will make the assumption that other people know more than we do," he said.
He isn't saying, "hey, isn't it far out how our brains switch off in the presence of experts?" He's saying, "why would you blindly follow these so called experts?"

The irony of he himself being an 'expert', and people blindly following him, is lost on him.

II.

He can't possibly be saying we shouldn't listen to experts, can he?

The point of having an expert is to trust his judgment. If your judgment is nearly as good as his, than either he's not an expert, or you are.

Being an expert entails more than simply amassing information; this is why having an internet connection and the first season of House does not make you a doctor. It is why a Prescribatron will be a worse doctor both at the individual and the population levels (more on that someday.)

He must know that the average person could not hope to learn enough information on finance (or medicine, or law, etc) to be usefully critical of an expert's opinion. (Or, the reverse: if you could, you'd be an expert.) In keeping with "a little knowledge is a dangerous thing," not trusting the experts and doing it on your own could be more disastrous. (e.g. crash of 2000.)

So why is 'expert' in scare quotes? Does he think those guys really don't know anything about finance?

Berns says his research highlights how we should pay more attention to financial advice and question the motives of so-called experts, assessing their trustworthiness before submitting to their opinion.

Of course: financial experts aren't dumb, they're corrupt.

The real brain glitch is the one that assumes that anything that is attached to money is corrupt. Or, more precisely, we can best judge the truth by knowing a person's financial biases.

This is how the CNN piece ends:

"Frankly, we should have everyone in the finance industry submit to brain scans," he says.

Ha! That's hilarious, especially since it was the exact opposite of the point of his study-- wasn't it the people seeking advice that were the problem? See how much fun it is to distort science, even good science that you yourself conducted and has value up until the "Discussion?" Here, he flips it around to say that the problem is with the experts. Which is, of course, what he wanted to be true all along.

I'll wager he would never put "neurology expert" in quotes, because he isn't tainted by money. (Well, government money, but nihil obstat.)

Meanwhile, because he doesn't "make money" on his studies (which of course he does) we're supposed to assume this is pure science-- accept it at face value. "Well, it uses MRIs." The MRIs are a rhetorical trick. They make it so you don't notice the political/institutional/personal biases. How much money a guy gets paid is all we need to know to judge his honesty.

"No, it's the source of the money that matters." Oh. If I do a study on Geodon that fails, I have to disclose if it was paid by Pfizer. If I do a study on Geodon that fails and I am sleeping with the Lilly rep, I have to disclose if it was paid by Pfizer. Solid.

It's a little scary to think that science can be used by scientists to reinforce a populist bias, but there you go.

------------

I'm on twitter

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if enough people sign up, I'll (try to) make it worth it.

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===== ====== ===== The Last Psychiatrist: Is An Hourglass Figure The Ideal? Only If You're Weak And Stupid

I may have my own sexual preferences, and they may or may not involve rum and the high seas, but I know a political agenda masquerading as a journal publication when I see one.

I. Bigger Is Better, According To Science

and according to this bit of sophistry:

Until now, scientists (and apparently Western society) thought a curvy figure trumped other body shapes. The idea was based on results from medical studies that suggested a curvy waist-to-hip ratio of 0.7 or lower (meaning the waist is significantly narrower than the hips) is associated with higher fertility and lower rates of chronic disease.

See the "Until now"? Elizabeth Cashdan, Professor and Chair at the University of Utah, does not agree with this, nor with the medical studies that do. "Until now" means we are about to learn why all that is wrong.

An imperfect body might be just what the doctor ordered for women and key to their economic success, an anthropologist now says.
While pop culture seems to worship the hourglass figure for females, with a tiny waist, big boobs and curvy hips, this may not be optimal...
Now, she doesn't actually go back and find problems with the old medical studies.   No, she's reasoned it out.

II. Biochemistry Will Explain All
Before I explain what she's discovered, let me walk you through her logic. Women with "imperfect" bodies will be healthier and more successful because that thing which makes them "imperfect" also causes economic success and better health. If that doesn't seem improbable to you, wait till you hear her explanation: androgens.
Androgens, a class of hormones that includes testosterone, increase waist-to-hip ratios in women by increasing visceral fat, which is carried around the waist. But on the upside, increased androgen levels are also associated with increased strength, stamina and competitiveness.
So masculinized women are stronger and smarter than feminized women. Or: paint will stain your fingers; paint can also make a beautiful painting. So if you see stained fingers, expect to see awesome art.
The biochemistry isn't even accurate. "Androgen" is more than just testosterone. Testosterone can increase or decrease visceral fat, depending on what you start with, whether you are taking the testosterone exogenously; or whether increased fat leads to insulin resistance and overproduction of testosterone as a consequence; etc. Are bodybuilders loading up on androgens so they can increase visceral fat? Do women with larger waists have higher levels of androgens? Etc.
The science only needs to be partially accurate, so long as she generates the conclusion she wants:
Cortisol, a hormone that helps the body deal with stressful situations, also increases fat carried around the waist.
Saying cortisol helps the body deal with stressful situations is like saying getting shot in the face helps you deal with the pain of being shot.
III.   The Bell Curve
It's important to understand that she's not trying to promote a theory that androgens are good-- if she was, she'd measure them directly, or use a better proxy (muscle mass, bone density, etc)- she's trying to come up with a justification for why an "imperfect body" is better than an hourglass.
In addition, past research has revealed that men prefer a ratio of 0.7 or lower when looking for a mate. The preference makes perfect sense, according to evolutionary psychologists, because the low ratio is a reliable signal of a healthy, fertile woman. Along those lines, Playboy centerfolds tend to have a waist-to-hip ratio of 0.68, Cashdan found.
So if all this is true, what lead her to think that larger waist size was a health and economic advantage, not simply unrelated, or even a disadvantage? You're going to want to lie down; within any scientific article that isn't scientific lurks a social agenda, and here it is:

Until now, scientists (and apparently Western society) thought a curvy figure trumped other body shapes... However, women around the world tend to have larger waist-to-hip ratios (more cylindrical than hourglass-shaped) than is considered optimal by these medical and social standards.
That's it. Don't bother looking for more, there isn't any: most women don't have hourglass figures, ergo it's not optimal.
Here's what's wrong with America, right here:
Specifically, Cashdan compiled data from 33 non-Western populations and four European populations, finding the average waist-to-hip ratio for women was above 0.8. So if 0.7 is the magic number both in terms of health and male mate choice, Cashdan wondered why most women exhibit a significantly higher ratio.
She can't understand why the ideal isn't the same as the average. So she wants to create reasons why the average is the ideal.

"Waist-to-hip ratio may indeed be a useful signal to men, then, but whether men prefer a [waist-to-hip ratio] associated with lower or higher androgen/estrogen ratios (or value them equally) should depend on the degree to which they want their mates to be strong, tough, economically successful and politically competitive," Cashdan writes.
Got that? If he prefers the hourglass figure, it means he wants weak and submissive women. If he prefers the larger type, he wants someone strong who votes.

She's replacing old stereotypes with new ones. "All blondes are dumb" may be a heuristic we use, but we have the common sense not to admit it because it's a debasement, like currency: you artificially lower its value so you can get more from it. What makes Cashdan's stereotype particularly dangerous is it is a debasement pretending to be a positive. Here's the reverse of Cashdan's argument: "See? being dumb is good, because then you don't have to worry about all that science! A man will handle all that!"

These are just empty words, asserted as fact. Unfortunately, asserted by one with authority.

IV. "You're Paranoid Again."

You say: who cares about this study? First, that this sophistry is an an academic journal is bad enough-- it takes on the the status of "knowledge"-- and people can even use it as support for more sophistry. Deny this isn't possible:

It has been shown that androgens can increase strength and economic advantage in women (Cashdan 2008.)
And then dare to try and publish against it.

Worse, the article made it all the way to the popular press-- or was that the point?-- even Newsweek crowed with glee, "Hourglass Figures: We Take It All Back"-- which means it becomes part of the knowledge base of people. Even if they're skeptical, they have to contend with it.

Do you think this is about making women feel better, or bashing male stereotypes? It's about taking one's own opinions about society and using "science" to affirm them. You'll be seeing a lot of this in the era of Keynesian Psychiatry. Debasements pretending to be positives. Explanations using "evolution," or worse, "evolutionary psychology." And, of course, the insistence that someone pay for it.

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===== ====== ===== The Last Psychiatrist: Is Cho The Question?

Quick speculation. As 13 year old kids like this usually create an identity from multiple sources- so far we're pretty sure the main movie was Oldboy-- I wonder if he didn't also identify with the Question (the comic). He signed his name as a question mark, he wore the same baseball cap, gloves with short sleeve shirt. And, in case you weren't once a lost male adolescent, the Question is Vic Sage, ex-philosophy major turned TV reporter who is also a vigilante. And the 30+ issues are all about his struggle with identity.
None of this is relevant to why he did it, of course. It's fun to speculate, but of no predictive value. These are costumes, roles. They just help him "get into character," which in this case is a man alone fighting injustice, greed, and abuse, using whatever tools he has. Of course, he was fighting college kids, and his tools were semi-automatics, but who am I to dispel a good illusion?
Finally, let me reiterate that the presence or absence of mental illness is irrelevant, at least as far as prediction goes. So let's say he was a violent schizophrenic. Would you jail him before he commits a crime, just in case? Bush does that with Guantanamo, you know. Do you send him to a psych hospital, like they do/did in the USSR? That process will be magnificently abused by your government, I assure you.
More posts on Cho here, here, here, and here.

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===== ====== ===== The Last Psychiatrist: Is Genetically Modified Food Safe?

uh oh

A recent study on the safety of genetically modified food is important for two reasons:

1. This is the first of its kind (!)
2. This is the longest in vivo study (in animals) on the safety of this food: 90 days. (!!!)

Rats were given one of three strains of genetically modified corn, or a non-GM corn feed, and studied for 90 days.

The results were not encouraging,

Our analysis clearly reveals for the 3 GMOs new side effects linked with GM maize consumption, which were sex- and often dose-dependent. Effects were mostly associated with the kidney and liver, the dietary detoxifying organs, although different between the 3 GMOs.

For example:

While these are not gigantic results, keep in mind that these are rats are eating at most a 33% mixture of GM corn, and it's only for 90 days. If you want to know if they cause cancer, just check with your kids in a few decades.

II.

It's not obvious to me how eating something with modified DNA is harmful. When you eat DNA, you don't incorporate bits of it into yours, any more than when you eat a pie you incorporate bits of pie.

One corn (NK 603) was modified to be able to withstand the plant killer Roundup, and two others (MON 810 and 863) were modified to produce an insecticide. When you eat this corn, therefore, you are also eating some herbicide or pesticide. In other words, it may not be the GM corn itself that is toxic. If the corn is grown on a farm that is sprayed with Roundup, then you're eating Roundup. It's quite possible this study is measuring the toxicity of Roundup, not GM corn.

Put another way: maybe they should find better ways of washing the corn?

III.

Does washing corn-- or anything-- help remove pesticides?

A.

In one study, water alone was tested vs. Fit Fruit And Vegetable Washing Kit.

Three points:

1. Study 1 fruit had been treated only with captan; Study 2 fruit was treated with a mixture of captan and methomyl.

2. Water and Fit both wash off captan well, but water isn't as good for methomyl, probably because fruits are coated with wax after they have been treated with pesticides, locking in the deliciousness. Water doesn't penetrate wax, but ethanol (in Fit) does-- as does rubbing the fruit. Moral: scrub wash, then peel, then wash your fruit. Soaking them in rum is helpful and delicious but not recommended.

3. This is what they mean by washing: soaking the fruit in 2L of water for 30 seconds, then rinsing it four times, 30 seconds each. Then rinsing again for 5 seconds with 2L fresh more water.

B.

An older study found that water was as good as Fit and even washing in 1% (!) Palmolive, significantly reducing 9/12 pesticides studied. (It had no effect on 3 others, so there's that.)

C.

What about meat?

While many pesticides have been banned (e.g. DDT) they are still in the soil and get incorporated into the plant. In a similar manner, current pesticides are theoretically incorporated into the fat of the farm animals that eat the sprayed plants and feed.

A study done in India found various meats (cow, goat, chicken) to be contaminated with several pesticides, including DDT. None of the animals appeared sick prior to their slaughter. However, and this is the point:

Cooking means steam (in a pot.)

I'd guess that cooking vegetables probably has the same effect.

---
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===== ====== ===== The Last Psychiatrist: Is Internet Addiction Really An Addiction?
Depends on your definition. Wovon man...

Keith Bakker, the founder and head of The Smith & Jones Centre, Europe's first and only clinic to treat computer gaming addicts, has changed his mind: 90% of the hardcore, multi-hour gaming addicts are not actually addicted.

These kids sure look like addicts:

"These kids come in showing some kind of symptoms that are similar to other addictions and chemical dependencies," he says.
"But the more we work with these kids the less I believe we can call this addiction. What many of these kids need is their parents and their school teachers - this is a social problem."
The clinic he runs is a rehab, for all addictions-- alcohol, drugs, etc-- it just happens to be the only one offering treatment for internet addiction using the same model. And he's abandoning it.

"This gaming problem is a result of the society we live in today...Eighty per cent of the young people we see have been bullied at school and feel isolated. Many of the symptoms they have can be solved by going back to good old fashioned communication."
The article goes on to cite the causes you'd probably guess at:

Not feeling accepted in real life
rejection, alienation, anger
anonymity allows you to be anyone you want
games offer you the identity affirmation one so desperately craves

Mr Bakker believes that if there was more commitment from parents and other care givers to listen to what their children are saying then these issues of isolation and frustration could be dealt with at source and bring many young people out of the virtual world and back into real life.
Adults do not take the time to really listen to "kids" as autonomous entities, we treat them either as extensions of ourselves or as pets.

"If I continue to call gaming an addiction it takes away the element of choice these people have," he says. "It's a complete shift in my thinking and also a shift in the thinking of my clinic and the way it treats these people."
The main novelty here is that it's an addiction specialist who is making this concession, admitting that most kids, regardless of how long they are playing, aren't addicted.

Hold on-- none of those kids are Chinese, are they?

II.

The debate about what is and isn't an addiction is a red herring. It creates a false dichotomy. Whether it is a compulsion or bad behavior doesn't change the fact that the person needs to stop, and often can't for whatever reason, and needs help stopping.

Focusing on the false dichotomy as the reason for treatment does have several consequences.    We don't know addiction is a disease, we think it's a disease. It's entirely possible twenty years from now we will discover it actually isn't. Then what? Kick the junkies to the curb?

Secondly, it makes control the central issue in its "treatment. "Loss of control is both the hallmark of addiction and the source of its societal stigma," said one of the country's leading addictions psychiatrist. If/since that is true, then it implies control must come from the outside.

You should probably stop reading right here.

III.

First the Germans were going to take over the world in the1940s; then the Russians in the 60s. Then the Japanese in the 80s. Then the Chinese in the 2000s. Perhaps every generation's parents need some foreign nation to scare their kids into better SAT scores. But history is clear that when a bubbles bursts, it gets replaced, not reinflated. Put away your Berlitz tapes.

A quick survey of national bubbles also serves to support my contention that nations in decline turn quickly to one of two things: completely whacked out pornography, or fascism, or both.

China-- where they have recently classifed internet addiction as a full blown psychiatric disorder, has invested considerable money and resources into treating it.

USAToday describes a Chinese clinic:

"All the children here have left school because they are playing games or in chat rooms everyday," says the clinic's director, Dr. Tao Ran. "They are suffering from depression, nervousness, fear and unwillingness to interact with others, panic and agitation. They also have sleep disorders, the shakes and numbness in their hands."

You can sense their frustration: whatever the cause, genetic or social, it's a big problem that is taking possibly two million kids out of circulation.

But classifying it as a psychiatric disorder-- that the element of choice is absent or decreased-- means that the state can "offer" you treatment if it thinks you need it.

We do that in America, too-- involuntary commitment laws, etc, for those to ill to take care of themselves. The difference is that "internet addiction" is sufficiently general that it can be defined by whatever group is in charge of setting definitions-- in this case, the government-- at any time they want, ad hoc.

Perhaps you're an iconoclastic blogger who thinks China blows?   A couple months at Daxing Boot Camp-- I mean Treatment Center-- will straighten you out.

IV.

Suddenly, that false dichotomy isn't so false anymore; suddenly, it matters very much if it's an addiction, or not.

Which brings me to my very unpopular position on this issue, toxic to any self-respecting Kantian: we shouldn't try to find out if addictions are diseases or not.

Society is often not ready for the answers to some "scientific" questions. As a society, we shouldn't be too quick to want addiction to be a disease, or criminality to be biologically based, or intelligence to be genetic, because we have no ability to deal with the consequences of those truths. We're barely muddling through now, and that only because not knowing allows us to slide back and forth along the spectrum, as situations require.

So many arguments are really the result of inconsistently applied definitions. The reason we have endless debates is that we have no agreement on what an addiction is. Is the primary characteristic a loss of control; escalating use; the presence of tolerance and withdrawal; etc? Not even all drug addictions have all those things. And without rigorous definitions, you can't have a scientific inquiry into the question. You may as well try to find out if sexism is a disease, keeping in mind that our understanding of sexism has been very different over the course of, say, 2000 years-- not to mention our conception of disease. How does science determine the biological correlates of something whose definition is applied inconsistently, influenced by prevailing cultural standards? You don't. Wovon man nicht sprechen kann, daruber muss man schweigen.

Furthermore, these words have connotations which are more important than their actual definitions, should they even exist. You can never fully erase these connotations. When a scientician says that gaming is an addiction like cocaine addiction, a gamer hears, for example, that the scientician means it is "bad."    So no matter how much data, MRIs, southern blots, genetic markers you show him, for him the issue isn't biology, but morality. The result of this is that rather than the scientician spending time making a case for why gaming can be an addiction, the real thrust of the argument is convincing the kid that addiction has a different meaning. In other words, the discourse isn't about science, or what is true; it's about semantics. In other words, a complete waste of time. Both interpretations are equally right (or wrong) because the word addiction means what you want it to mean.

Doctors love to identify biology in such things because it allows them to assit in making social policy. Doctors have no place there, they not only have nothing to contribute, their contributions should be assumed to be folly.

Arthur C. Clarke said either we are alone in the universe, or we are not. Both are equally terrifying. Everyone agrees that one of those two has to be right; but as long as we don't have to answer it, we can go on with our lives.

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===== ====== ===== The Last Psychiatrist: Is More Regulation Needed?
I know disagreeing with Daniel Carlat is like disagreeing with Obama-- how can you?-- but someone has to.

The article is called, "Has the regulation of physician-industry relationships gone too far?"

Dr. Daniel Carlat starts with a rhetorical trick, conceding ground at the outset thus establishing himself as a practical centrist and not an ideologue, and then stealing the ground back. Remind you of anyone?

I disagreed with many of the presenters but was in absolute agreement on one point: interaction between industry and physicians is a good thing. It is crucial to scientific progress.
It's an election year trick. Carlat followers already know exactly where he is coming from; so conceding this much isn't going to turn them off. "It's politics. He has to say that." Those who don't know him can be soothed by what sounds like a reasonable voice.

But suppose I want to find out whether Drug A is better than Drug B. Would I go to Company A for this find of advice? Of course not-- this is the last place I would go.
I realize this seems unassailable, but it's not only theoretically wrong, it's actually false.

First, Company A can't actually say it has a better drug than Company B. It's illegal. They can't even tell you about a published study, even one they didn't do. (Don't worry, I'm sure doctors will come across it on their own.)

Second, if it was allowed, why wouldn't you want Company A's answer? It may be biased, but you already know the bias, and they're not allowed to lie. Does Company A have nothing useful to say? Then you can ask Company B what they think. Isn't that how people pick their President?

But here's why it's actually false:

Likewise, I would not go to a physician paid to promote Drug A for this advice. I would go to a source without that conflict.
He means a unicorn. It does not exist.

In fact, he does go to Company A for the info, he just blinds himself to it. The studies, academics, Departments, journals, reviewers-- all are eye deep in Pharma money. "It's not Company A money." Oh. So when a Republican senator who does not get oil money votes for an oil project, you figure he conducted a dispassionate analysis of immediate energy needs vs. environmental/climate impact?

II.

... I know about human nature. When you have a financial incentive... you will respond to that incentive.
I know something about human nature, too: more powerful than money is the desire to maintain identity. Narcissism. When a politician "gives the money back" in order to keep his job, he's not doing it because the job will get him more money, he's doing it because the job is more important than the money-- it's his identity.

Your identity is so powerful that it actually biases other people more than money. Look back at my Republican/oil example. It fit perfectly, it made sense to you. But if I had made a Democrat/labor union analogy, it would have rubbed you the wrong way, even though they are equivalent. You're biased, and for cheap.

That's why a man free of financial bias may be trustworthy, but he is not trustable. Where's he coming from? Is he pushing Depakote because he "believes" it? Because his son, N=1, responded to it?    Because he works at a university where antiepileptics are the cause du jour? Because his Depakote rep is hot?

I don't particularly want financial bias in my academics, but to single that out as the main source of trouble in our field is like singling out the elbow as the pivotal component of matricide.

III.

This is the same error people make about the need for government intervention, e.g. that the "free markets" have failed and more regulation is obviously needed. Even if one were to agree on principle that people can't be trusted, the mistake is in forgetting that government is people. These people are subject to the same biases, cognitive errors and general prejudices as the guys at Goldman Sachs, albeit currently it in the opposite direction. We can argue that we prefer the government's biases, but one cannot argue that the government is less biased, self serving, or corruptible.

This may originally have been a country of laws, not men, but that's not the country most modern people want; they want to be able to alter the laws to suit the times. Fine, it's your country. But understand that if the laws are subordinate to men, then the enforcers of those laws will always have more power than you. Has anyone tried to get an anti-Depakote study published in J Clin Psych in the past decade?

It's excellent that Daniel Carlat thinks doctors like himself cannot be trusted to read and interpret their own studies, and that some other group of-- doctors? lawyers? what?-- with special bias-immunity rings need to be assembled to protect us. But those people are still people. This is why the NIH, with their incestuous grant reviewers, crazy politics and flavors of the decade philosophies is so dangerous-- they're just as biased as Pfizer except you think they are objective.

In other words, before I agree to being regulated, I want the names of the people regulating me, so that I can at least laugh at the irony.

I am asked all the time, "where can I go for unbiased information on medicine?" My God-- if the physicists don't have such a place, do you really think that medicine does? And why does no one ever ask where they can go for unbiased political information?

People would do well to remember that at one point in our nation's history, "government" was George Bush. When you argue that government needs to be more involved, you are arguing that George Bush needs to be more involved. I do not trivialize this discussion by offering Barack Obama as an equivalent example of the government you want so desperately to supervise your lives.

----
also: The future of bias

---

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===== ====== ===== The Last Psychiatrist: Is Obama Inspiring Black Adults To Step Up? The Nature Of Altruism, Part 1

no, I got this

This isn't about race. So take a breath, let's go.

CNN article, "Is Obama inspiring black men to step up?"-- in this case, to become a Big Brother/Big Sister volunteer.

[Obama] was giving a televised speech challenging men to get involved in their communities. The men [gathered in a barbershop] had heard the message before, but this time they could relate to the messenger. Obama had shared their struggles...but had never used his struggles as an excuse. Nor could they anymore, some of the men decided. Seven joined Big Brothers Big Sisters of America that morning,
It took Obama to make this happen-- no prior figures of inspiration? Is the resolve of someone who impulsively joins the Big Brothers because the President was making a speech worth betting on? etc. But, in fact:

At the Atlanta chapter of Big Brothers Big Sisters, Rita Owens, the vice president of development, says she hasn't seen any more black men volunteer since Obama was elected.

"We can't see any influx of black men volunteers," she said. "We do not have enough black men stepping up. We have more Caucasian men stepping up."

Before you start talking race, my first thought reading this was about 9/11.
I was working a hospital that day, and many people, especially nurses, wanted to go to NY to help out. But they wanted to take off work to go do it. In other words, they wanted to volunteer instead of doing their job. "But they need volunteers!" they'd argue to the refusing nurse manager. "We all need to make some sacrifices." Of course, in doing so, they were volunteering the people left behind for double shifts. That's the part they didn't seem to get.
So here, "seven joined Big Brothers Big Sisters of America that morning." Great, they want to help a young boy in need of a role model. But do these men have kids of their own? It's one thing if they're living with their kids and want to give something extra to others. But if they're living apart from their own kids, why not just spend extra time with them?
Because doing "your job" isn't as rewarding as "sacrificing."

Here's what happened on 9/12 at my hospital, and what happens in so many cases of high-emotion altruism: they take the day off in order to go to NYC, but then don't actually go (car wouldn't start; heard on the radio they were blocking volunteers, etc). They win: they get the reward of the sacrifice, perform no actual sacrifice, and get the day off. Meanwhile, someone else had to sacrifice to cover their responsibilities.

I think Rita Owens meant the statement "more Caucasian men stepping up" as a jab at blacks to get them movitated, but if it is factually accurate then these Caucasians are idiots. Really? Big Brothers? That's the call you heard? Whites seem particularly prone to manic devotions to faddish volunteerism inspired by celebrity that are transparently self-aggrandizing. And temporary-- they inevitably quit when the next fashion comes along. Keep in mind that the Caucasians she is talking about joined Big Brothers not because they just learned it existed, but because they were inspired by Obama. How long is that going to last?
"How can you even question the integrity of someone who joins Big Brothers?" I'm not. I'm questioning the integrity of someone who is going to soon quit Big Brothers. I'm questioning what message that delivers to a) their real kid; b) the kid they will be soon abandoning.
It's going to take way more than Obama to generate any kind legitimate social consciousness in us. No, I don't mean a Prius/vegan sort of consciousness, just the basic kind where we are aware that all of our actions have a blast radius, and other human beings are in it.

II.

What is not intuitively obvious is the psychological motivation of the people left behind: why do they do double duty and let these fakers get away with it? Why, when the man says he's going to spend resources on someone else's kid, does the biological mom of his kid not hit him with a sack of batteries? More importantly, why has this complementary behavior (guy volunteers, other guy forced to pick up the slack) been allowed to exist in human society? We don't pee on each other anymore, so why do we allow this?

There are two ways to look at it:

By definition, altruism means sacrifice; if there's an emotional "I want to help!" benefit, then it's not purely altruistic (doesn't make it bad, just not altruistic).

Or you can take a strictly biological view of altruism: it results in a decrease in reproductive fitness, i.e. progeny. Biological altruism doesn't care about intent; only that the action benefits others at reproductive cost to itself.    Worker bees, who give up their ability to procreate, behave altruistically. The above volunteers, also under this definition, are not behaving altruistically.

If you want to stick to evolutionary psychology, then the behavior of the above volunteers can be understood as the opposite of altruistic, it is self-promoting in the interest of reproduction. In other words, these temporary displays of volunteerism are chick magnets.

But under almost any definition of altruism, the real altruists are the ones left behind. The worker bees who gave up sex for hex.
Think, for a moment, why you think worker honeybees are worker honeybees. You probably figure it's "genetic" i.e fixed, but honeybees are totipotent-- the females, as larvae, can become either queen or worker. Furthermore, as adults, they can choose to change again, by activating or deactivating their ovaries. It's up to the individual, not decided by God. Despite this, 99% of females decide to become sterile workers.
The reason they do is twofold. First, the amount/kind of food given to larvae is restricted so that there isn't enough to become a queen.   Next, if a female chooses to have some babies, those babies are promptly killed by the other adults, with amazing efficiency. This process discourages the workers from laying any eggs in the first place. This isn't some slow evolutionary process; they're actually killing babies in there, on purpose. This is a guaranteed way of getting the civilization you want, and fast.

When there is no queen in the hive, the killing of babies is reduced or stopped, until a new queen is made.

The altruism of worker bees is socially coerced.

Part 2 coming.
----

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Is Schizophrenia Really Bipolar Disorder?

The answer should be so obvious that there shouldn't be an article on it. But there it is.

Lake and Hurwitz, in Current Psychiatry, conclude that schizophrenia is really a subset of bipolar disorder.

The author's initial volley is (sentence 3):

The literature, including recent genetic data (1-6) marshals a persuasive argument that patients diagnosed with schizophrenia usually suffer from a psychotic bipolar disorder.

Well that's a pretty powerful assertion, supported by 6 different references. Except for one thing: none of the six references actually support that statement.

Berrettini: finds that of the various regions of the genome connected to bipolar disorder in genome scans, two are also found in scans of schizophrenia. Regions that overlap-- not genes, or collections of genes, but entire chunks of chromosomes. He says there are (perhaps) shared genetic susceptibilities, not that they are the same disease.
Belmaker: A review article. No new data.
Pope: specificity of the schizophrenic diagnosis-- written in 1978.
Lake and Hurwitz: says there's no such thing as schizoaffective disorder, which would be groundbreaking stuff if it weren't written by the same author as this article.
Post: Review article talking about kindling in affective disorders. In 1992.
DSM-IV. Seriously.

I'm game if you are: find the "persuasive argument" that these references "marshal" and then we have something to talk about. What makes all this so hard to fathom is not the movement to lump the two disorders together, but rather to lump them together under the more arbitrary, heuristic diagnosis. It is schizophrenia, not bipolar, that actually has physical pathology. Let's review:

Brain anatomical findings:

white-gray matter volumes decreased in caudate, putamen and nucleus accumbens. 1
deficits in the left superior temporal gyrus and the left medial temporal lobe.2 3
moderate volume reduction in the left mediodorsal thalamic nucleus (but total number of neurons and density of neurons is about the same) 4
reduced gray matter volume, reduced frontotemporal volume, and increased volume of CSF in venticles 5 and 1

Physical features:

Larger skull base and larger lower lip 1
Velo-cardio-facial syndrome (22q11 deletion) 2
vertical elongation of the face 3
high arched palate 4

Granted, these aren't great; but try to find anything like this for bipolar.

Clearly, the Kool-Aid is delicious because they want us to drink it, too.

In the final section, magnificently entitled "What is standard of care?" the authors pronounce:

Antidepressants appear to be contraindicated, even in psychotic bipolar depressed patients.^14,15 We suggest that you taper and discontinue the initial antipsychotic when psychotic symptoms resolve.

Which is great, except it's not true. If the authors have some evidence that antidepressants actually increase the switch rate, I'd love to see it: but for sure references 14 and 15 aren't it. At least, could "contraindicated" be a tad overstated?
The last two sentences of the whole article:

The idea that “symptoms should be treated, not the diagnosis” is inaccurate and provides substandard care. When psychotic symptoms overwhelm and obscure bipolar symptoms, giving only antipsychotics is beyond standard of care.

No references given for these outrageous statements, but given the relevance of their previous references I guess it really doesn't matter. "Substandard care?" "Beyond the standard of care?" Really? I'll see you in court.

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===== ====== ===== The Last Psychiatrist: Is Taking Nothing Legal?
Provigil, a "wakefulness promoting agent," is banned at the Olympics, even though, probably, it has no effect on physical performance. Despite what the Olympics says, it isn't a stimulant.

If Provigil has any effect on a specific athlete's physical performance beyond keeping them awake, I'd argue it was placebo effect. So a drug with a placebo effect is illegal. Fine.

But what about the reverse situation: what about giving an actual placebo to an athlete, and telling them it's oh, I don't know, growth hormone? Or Ritalin?

The Economist describes a study in the Journal of Neuroscience in which repeated precompetition doses of morphine were then replaced by placebo on the day of competition; the placebo, like real morphine, helped them endure pain during the competition. In fact, the placebo had an opioid- mediated analgesic effect (the effect was prevented by the opioid antagonist naloxone)-- it may as well have been actual morphine. So now what? Ban placebo?

Well, you say, the simple solution is to ban substances not just in competition, but during training as well; say, 2 years before a competition. Except you can't ethically ban pain killers during training-- can you?

It should be mentioned that the World Anti-Doping Code bans any "substance or method [that] has the potential to enhance..." so I suppose placebo-doping is a technical violation, though it's hard to see how anyone could catch it. Perhaps the solution is to monitor the amount of morphine used pre-competition as a clue to the "method" (unreasonable amounts of morphine daily might suggest...)    Perhaps, but in this study the placebo effect was seen even after only two morphine doses, separated by a week.

I bring this up not because I'm worried about "placebo effect conditioning" (hasn't really caught on (I think...)), but because the idea here speaks to several social questions. Do we care about what causes something, or what was caused? Do we ban the specific substance morphine, but leave open the pathways of analgesia, or do we ban opioid-mediated techniques, e.g. anything that promotes analgesia?

Sports are fun, I'll admit, but let's take this exact study and alter it by a word. Replace "competition" by-- murder. I don't think it's hard to imagine morphine "facilitating" a murder. (Forget about whether it actually does or not; just accept with me that it's not totally preposterous.) So? Two doses, separated by a week, with a placebo response on the day of murder?

You say: come on, that's pushing credulity. Ok. Replace competition/murder with-- car accident. And the issue can be used by both sides: DA: "Your honor, I know he didn't actually take any morphine that day, but he thought it was morphine, so his intent was to DUI, and, in fact, technically it was a DUI." Or, defense: "he wasn't fully responsible for the accident-- he was drugged by placebo."

This extends to discussions on the impact of psychiatric disorders on behavior. Ready? Oh, you're not ready. Ready?

I've discussed how labeling a person as a psychiatric patient earns them certain privileges not afforded to regular people. The malingering guy in the ER, who does not actually have a psychiatric illness, who then shoots the psych nurse, gets to argue that he is a patient by virtue of the fact that he is in the ER. I'm not saying he'll win, just that he gets to argue it. Well, imagine this: a psychiatrist erroneously diagnoses someone with bipolar disorder. Does the knowledge of "having" bipolar disorder change the person's behavior? I don't simply mean that he begins to act "bipolar;" I mean does he become bipolar, physiologically, in a placebo effect fashion? (If it helps, imagine you erroneously diagnose someone with diabetes, and this causes a reflexive hyperglycemia.)

If you say, "but that doesn't actually happen" then you are missing the point. The point is that any interpretation of behavior or identity as context specific is always artificial, and always inadequate. Saying someone did something because they were bipolar puts a primacy on the bipolar that is completely arbitrary. You may as well say astrology was involved. Oh, silly? But 1500 years ago it would have been silly to blame bipolar over God and the stars. If you want to put behavior in the context of bipolar, then you have to put the bipolar in the context of 2007, which has to be put in the context of the Nazis not winning WWII, which has to...

To even fantasize that you have some ability to quantify the contributions of an infinity of forces on an otherwise "volitional" action is to assume not that God doesn't exist, but that you are God. That you know what counts and what doesn't when in talking about a behavior.   That you see through the Matrix.

That's why, ultimately, a man has to be judged on his actions, not on his identity. Anyone can be anyone they want to be. But no one can do what they don't want to do.

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===== ====== ===== The Last Psychiatrist: Is The Cult Of Self-Esteem Ruining Our Kids?

what does the author want to be true?

The article is called How To Land Your Kid in Therapy, it's in The Atlantic, and this is how it dares to start:
If there's one thing I learned in graduate school, it's that the poet Philip Larkin was right. ("They fuck you up, your mum and dad, / They may not mean to, but they do.")
Get the rum, we're going to need it. No, all of it.

I.
Lori Gottlieb is a writer for the various outlets that pose as intelligent-- Slate, NPR, Salon, whose demo is people who use the word "inappropriate" and know there are no wrong answers. She also wrote a book called, Marry Him: The Case For Settling For Mr. Good Enough which roughly coincided with her never marrying anybody.
Other than submit articles to The Atlantic, she did something else that a lot of confused, directionless people do: she became a therapist. Easy, everybody, hold that thought for a minute, we'll come back to it.
But soon I met a patient I'll call Lizzie. Imagine a bright, attractive 20-something woman with strong friendships, a close family, and a deep sense of emptiness. She had come in, she told me, because she was "just not happy." And what was so upsetting, she continued, was that she felt she had nothing to be unhappy about. She reported that she had "awesome" parents, two fabulous siblings, supportive friends, an excellent education, a cool job, good health, and a nice apartment... So why did she have trouble sleeping at night? Why was she so indecisive, afraid of making a mistake, unable to trust her instincts and stick to her choices? Why did she feel "less amazing" than her parents had always told her she was? Why did she feel "like there's this hole inside" her? Why did she describe herself as feeling "adrift"?

I was stumped.

I'm not surprised. None of those variables have anything to do with happiness. Any way Lizzie has of identifying herself based on something she's done rather than something she has or is? Any of those characteristics a verb? No? (1-- read the footnotes later.)
So I'm not surprised Lizzie is unhappy, the question is whether Lori, as her therapist, should have been surprised.
Maybe she was, maybe she wasn't but she spends 4 pages explaining that kids today are coddled, given everything, protected from harm/hurt/failure and squeezed into bike helmets, and this has the terrible effect of creating wandering, unfulfilled, depressed adults. Too-perfect parenting has made the kids soft.
That may be the thesis of article, and it may be factually accurate, but boy oh boy is it not at all the reason she wrote it, or why it's the cover story for The Atlantic.

II.
In order to understand what is the real cause of the ruin of children, what makes them into "narcissists" (her word), you have to look carefully at why this story is in The Atlantic. I don't think even the lifetime subscribers in Westchester, NY turn to The Atlantic for the current scientific data in psychology, and no one turns to Gottlieb for parenting advice. They're coming because they already know the answer they want to be true but want it stated more eloquently. What does it say better than its readers could, that confirms their own beliefs?
Let's go through it. When confronted with Lizzie's unhappiness, what is the first thing Gottlieb considers?

Where was the distracted father? The critical mother? Where were the abandoning, devaluing, or chaotic caregivers in her life?
Bad parenting, ok, fair guess. But, as the title of the article reveals, it's actually good parenting, overparenting, coddling. Do we all agree? Please observe that while this may be the opposite problem, it is in fact the exact same psychic solution: unhappiness is not your fault, it's caused by someone else. Jot that down, we'll come back to it later.

Consider a toddler who's running in the park and trips on a rock... some parents swoop in immediately, pick up the toddler, and comfort her in that moment of shock, before she even starts crying....
"Well-intentioned parents have been metabolizing [the kids'] anxiety for them their entire childhoods," [psychologist] Mogel said of these kids, "so they don't know how to deal with it when they grow up."

The above consonants and vowels completely correspond with the preferred logic of Atlantic readers, but I'd like you to consider, for a moment, the kind of atrociously malignant parent that does not rush to comfort their toddler "even before she starts crying." Are you raising a ninja? "I just let her feel the burn, get used to the sight of blood. Builds character."   Pass me that hammer, I want to build your character.

No one who doesn't eat human flesh would let their kid cry and do nothing. So what is the purpose of this logic if it actually defies reality?

Take a second and consider the likely offenders of this style of "too-perfect," rush to protect overparenting. Do they have mullets?   No. Live in Daytona? No. Do they read Sports Illustrated? Guns & Ammo? No, they read The Atlantic.

So the purpose of this article can't be to suggest to its readers they are terrible parents, and anyway they already suspect they're overparenting and that it is bad. They're turning to Gottlieb and The Atlantic for therapy, to be told that they are indeed overparenting but it's understandable... you have good intentions.

III.

And there's an awesome, unintentional subtext: parents are overinvolved with their kids because they want what's best for them, but this has the perverse effect of harming them, and so........... it's ok not to be. Why don't you get a facial?
It is certainly ok/infinitely preferable not to spend so much time with your kids. But saying you're doing it because it's good for the kids is like saying you're getting an Asian massage because it's good for Asians.

IV.

They didn't rush because the kid can't handle pain, but because they can't tolerate the kid's pain. They rushed to the kid's side because it protects the kid, yes,, but primarily because they can't handle the anxiety of it all. What's my role as a parent? What do I do?

I go through this because Gottlieb wants it to be true that the cult of self-esteem is ruining our kids, but the cult of self-esteem has already ruined the kids who are now adults. It produced her and her peers. And now they are raising new kids, well or badly I have no idea, but their main preoccupation isn't with raising better kids but with self-justification. This fact is completely lost on her.

As a parent, I'm all too familiar with this [entitled kids with too many options.] I never said to my son, "Here's your grilled-cheese sandwich." I'd say, "Do you want the grilled cheese or the fish sticks?"... He'd come to expect unlimited choice.

Guess what six words she says next.

When I was my son's age, I didn't routinely get to choose my menu, or where to go on weekends--and the friends I asked say they didn't, either. There was some negotiation, but not a lot, and we were content with that. We didn't expect so much choice, so it didn't bother us not to have it until we were older, when we were ready to handle the responsibility it requires.
This is laughable coming from anybody, but is she unaware that she's written several books describing her own childhood psychiatric visits and teen anorexia? And serial dating culminating in nothing?   If I were a therapist, I'd label this as "poor insight."
The kid's problem isn't that he is offered too many choices at all. The kid's problem is that his mom believes these choices are the thing that will ruin him, that's where she sees danger, not TV or Xbox or learning violence is always wrong, but in choice.
There's no insight about the dynamic effects of a mother who feels compelled to offer him meaningless choices-- that she is discharging the anxiety of her own indecisiveness onto her kid. Fish sticks and grilled cheese may not seem like heavy decisions but there are consequences nonetheless, and if she doesn't have to bear them, she'd just as soon pass them on to a four year old.
I wasn't there, but I will bet ten thousand dollars that every guy she has ever dated has had the following interaction with her:

Guy: What do you want to do tonight?
Her: I don't know, what do you want to do tonight?
and:
Guy: I'm at Blockbuster, what movie do you want to rent?
Her: I don't know, what movie do you want to rent?

Jesus Christ, just say Officer And A Gentleman and let me get out of this death spiral.
Since she chose to go with doctor supervised immaculate conception, the kid now gets the job of sounding board for dinner choices. You know what choice she'll never offer him? The choice to fight back on the playground or disagree with her. Being given the illusion of free choice when all of the choices are meaningless or terrible has a name, and they used to think it caused schizophrenia, so grant me that it probably drives some kids to therapy.
A similar phenomenon is the parent who "has" to quit smoking, or drinking, or cursing, or whoring, or whatever, "now that I have kids."   So noble. Nothing better than making the kid a living replacement for your own hysterectomized superego. There is absolutely no chance, none at all, that your resentment of him will ever come through in your interactions. ESPECIALLY not when your kid one day tries these things himself. Impossible. Your parenting is rock solid.

V.
Along with the article, The Atlantic includes a video clip of Gottlieb interviewing another therapist. They did this because they are trying to kill me. If you want your head to ignite, fast forward the video to 1:05 and watch the next nine seconds, then call Universal Studios and tell them you're the next Ghost Rider.

It's worth watching the video, but here's what happens: brown haired Gottlieb introduces a smiling white hair and glasses Dr. Mogel, who responds:

Mogel: Hi, Lori.
(cut to Gottlieb)
Gottlieb: I just wanted to start off and say, it seems like this idea of ordinary is so----
(cut to Mogel)

The moment Gottlieb gets to the word "ordinary," Mogel nods her head vigorously in agreement and then starts writing something down. WTF is she writing?? a) it's an interview, b) Gottlieb hasn't even said anything yet, and c) Mogel's the one being interviewed!
So obviously it's a nervous thing, a reflexive gesture, sure, I get it, but what you and she don't get is that every time a therapist writes something down it's a nervous thing. They write to discharge their anxiety of too long looking into a person's eyes and it not leading to either "I love you" or "I'm going to kill you." I know this is going to run me afoul of every comfy-chair therapist in America, but there is no reason to write anything down, ever. You're not a detective, you're not looking for coded messages or lost time, the patient is there for answers and the structure of your relationship is itself the answers. Why does she like me? Why does she get bored/angry/expansive when I do this? Why did she continue with a therapist who is so uncomfortable around other people that they need a yellow pad as an emotional shield? Seriously, that's not an accident at all, answer that question and the therapy is done, the patient is cured.

We can discuss good and bad technique later; the point here is to establish that these two people are creating "environments" that are safe for themselves. It may also be safe for the patient, it may be labeled as "for the patient" but I hope it is evident that the real impetus is the comfort of the therapist. With me so far? Ok: that's also how they parent.
"Many of us went through psychoanalysis, and we learned the minutiae of despising our parents and all the horrible mistakes they made."
What kind of psychoanalysis did this woman pretend she went through? Only a two year old, a 16 year old or a narcissist hates their parents because of the less than perfect things that they did, and that anger, not the effects of the parenting, is where the focus of the therapy should have been. And yet:
Let your kids hate you sometimes, it's good for them. You don't have to always have them agree with you or have them always like you.
Note the phrasing-- this is good for the kids, which is actual kids, not the adults-that-were-once-kids. Adults' anger gets to remain justified.
And it's a lie anyway. Sure, it is good for the kids, but is there anyone who can't see that the primary reassurance is for the parents who can't handle being hated by their kids?

VI.
That Lori Gottlieb has had a life marked by free agency, drifting around from interest to interest, job to job, relationship to relationship; and having the unique luxury, first by parents, then by writing talent, of being able to afford such wandering; and that it all leads to therapy, not just as a patient but ultimately as a therapist-- is not at all an accident.
The old adage that shrinks go into shrinkage to figure themselves out sounds awesomely correct except that it's incorrect and inawesome. They go into it so they don't have to figure themselves out. Best way to avoid judgment is to become the judge. Overruled. I said overruled.
The therapist has a sanction to create narratives, and there's nothing better than being able to create a narrative that also defends your ego from all manner of attack. Actually, there is one thing better: be a therapist and a writer for The Atlantic. Now not only do you get to create the narrative, you get to make it the accepted wisdom. "I don't fall for it, I don't read The Atlantic." It doesn't matter if you read it, if anyone reads it, an article's publication in it makes it the default intellectual position of middlebrow America, and so if you want to disagree the burden of proof is on you, eat it. She wrote 500000 words justifying her depression as her parents' fault but her overparenting the result of "wanting what's best for my child" and now no one else has to, because it passes into conventional wisdom. "Oh, smart people are spending less time with their kids to watch Weeds."

It's the same way that an advertisement for a TV show you'll never watch can change the way you think about sex, because you think it is how everyone else thinks about sex, and now suddenly it is how everyone thinks about sex. The commercial-- not the show-- made it true.
Gottlieb wants it to be true that overparenting and artificial self-esteem is causing kids to become narcissists, but that's all defense. Overparenting doesn't cause narcissism, narcissism causes narcissism.(2)

Here's what a therapist should say: "too perfect" parents who coddle and overprotect their kids aren't doing it for their kids, they are doing it for themselves, in defense of their own ego; and that, not the bike helmets, is why their kids end up adrift and confused. The problem isn't that kids are too wussy to go out and play, but that their parents do not trust themselves, their generation ("if I graduated Wellesley and I'm this stressed out, that other mom must be a pedophile"), their impulses and instincts, so kids must be dandelions made of cotton candy in a rainstorm made of lava, which makes no sense yet it makes perfect sense: paranoia. Ego vs. reality, and you can't appraise either. And then one day your kid is punched by some bully raised by Nascar fans or baby mommas and you shut down the school because you think the problem is the bully. The problem is you. The bully may have punched your Edward in the belly but you mobilized a school district to DEFCON 2, who has more power? Who is the biggest bully?(3)
The problem is you are in therapy not to become better parents or to do better work but to... to what? Do you have any idea?
More than likely kids overcome all this, everybody finds their own way, but to those who feel stuck the only solution is to forsake all attempts at figuring out who you are, conveying who you are-- because you aren't anybody yet-- and just accomplish stuff, yet be ready to discover in 50 years that the sum total of your life's real accomplishments may be very different than what you expected, and it must be enough. In the irreplaceable words of Marshall McLuhan: "there's nothing God hates more than some mofo with a cable subscription running out the clock."
That'll be $250. You can pay at the window.

You may also like:
Marry Him! Or Don't

------------------------------------------------

--- Footnotes:

I've made this point before, but worth repeating: chronic, non-medical insomnia is a similar symptom of a lack of completion, accomplishment. All the usual suggestions (read a book, light exercise) are temporary accomplishments, which is why they work; and the other maneuvers (surfing the web, watching TV, drinking) are searches for something accomplishable. And nothing says accomplished like a Pornotron orgasm. Night night.
A technical correction: the typical premise, articulated by Twenge (top of page) is that artificially elevating kids' self-esteem makes them narcissistic, grandiose. But narcissism is not synonymous with grandiosity, not even close, and anyway high self-esteem should make them happier, not more anxious. More accurately, the unhappiness comes not from thinking they are better than they are, and not even from the inevitable future failures, but from not being sure how good they are, if they are good at all. They are not sure what is supposed to define them.   "How can you know what kind of a man you are if you've never been in a fight?" The important thing wasn't to win. The reflex defense of existential anxiety is to define yourself against something, not "I am this," but "I am not that." And where this is most harmful is the avoidance of guilt. "Yes I did this, but I am not the kind of person who does that, you don't know the whole story..."
Before you remember/reinvent how it was back in "the old days", here's the "sad" truth we just need to accept: we're never going back to the old way. There was a time you could slap your bitch or paddle your kids, and right or wrong you can't do that now and you will never be able to again. It doesn't matter if a little ass pinch at the office does improve productivity and morale, or treat zoster or prevent communism, it is never coming back.

And the moment the nerds responded to a couple of wedgies with overwhelming firepower, the moment they made the bullying "this shit just got real" real for everyone else-- right or wrong, sissy or not, bullying was done forever. If you're 11 and you punch a fat kid, let alone a gay fat kid, it's game over for you, they cancel your subscription to Weekly Reader and set you up for home schooling. Unless you're in an inner-city school, of course, and then you get wrap-around services, 6 years of Adderall and extra time on tests. We can spend the next 60 terabytes arguing whether this is progress or regress or whether America is soft or turgid, or we can stop wasting time comparing today to the day and just get on with the regular business of ordinary life.

===== ====== ===== The Last Psychiatrist: It's Either Narcissism Or Dementia
Michael Jackson's father gets interviewed.

I'm not making a diagnosis here, I've never heard him talk except in this interview, he could be so overcome with grief that he's not thinking straight...

... so allowing for that, observe how he makes the interview about himself. Narcissism doesn't mean you think you're the greatest person on earth, but rather that all things in the world are relevant only as they impact you.

CNN interviewer: The father of Michael Jackson, Joe Jackson joins us here tonight. How are you doing, sir, how is the family holding up?

Joe: I'm great. My family's doing pretty good.

CNN: Yeah?

Joe: Yes they are.

CNN: The last couple of days have been really tough...

Joe: ... yes, it has been tough, really tough. Remember, we just lost the biggest superstar in the world.

CNN: How is Mrs. Jackson?

Joe: She's fine, thank you.

CNN, clearly stumped: umm... is there anything you'd like to share with the world about your son and his legacy?

Joe: Yeah, I've got a statement here... give me this statement.. (publicist reads this statement while he watches:)

"Our family sincerely thanks all of you around the world for your love and support during our time of grief. Our beloved son Michael Jackson loved you all. Michael's children are our first priority. We will have further announcements to discuss our plans going forward. Until such time however, we have the personal and legal authority to act and solely Katherine and I have authority for our son and his children. We wish to handle his memory and legacy with dignity"...

CNN: How are Janet, and your wife, and the rest of your family, the daughters?

Joe: They're all doing fine. But I want to make this statement. This is a real good statement here. Marshall and I, we own a record company called... tell him... (Marshall finishes:) "Ranch Records, it's distributed by Blue Ray, and that's his next step."

CNN: That's the next step.

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===== ====== ===== The Last Psychiatrist: It's Not A Lie If It's True
Starring Megan Fox.

The Brown University Psychopharmacology Update ("The Premier Monthly Forum About The Use Of Psychotropic Medications") reviews studies. Their angle is that they don't have an angle, they are objective, they don't take Pharma money, and the editor has a beard.

"We don't usually report on industry-funded studies..." but "the findings are compelling."

Dig deeper, my friend, dig deeper.

I.

Randomized double blind multicenter trial of Zyprexa vs. Abilify. The study found that Zyprexa 15mg was better than Abilify 20mg, but that (from the study):

More patients experienced significant weight gain at Week 26 with olanzapine (40%) than with aripiprazole (21%; p < .05 [weighted generalized estimating equation analysis])

Brown University Psychopharm Update writes:

And the bonus point: the sponsor of the study, Bristol-Myers Squibb, is the manufacturer of aripiprazole [Abilify]. So, no surprise that olanzapine [Zyprexa] results in more weight gain than the sponsor's product, but surprising indeed that it is more effective.

Does he mean he's surprised that BMS didn't fudge the study? Come on, does he think that somehow BMS can alter the results of a double blind trial? How? Remote viewing? If the CIA couldn't get that to work, what chance does BMS? And if they could, do you think they'd be wasting their time with Abilify?

What's probably surprising to him, I think, is that untouched data that was negative for Abilify actually got reported for all to see. Yes, that is surprising.

Turns out, he was right to be suspicious.

II.

I had a thought: this is a study that exists-- e.g.in a public database-- but it was sponsored by BMS. It shows Zyprexa is better but Abilify is safer. In which company's marketing materials does this study appear?

The answer is, in Lilly's. The Zyprexa promotional materials show Zyprexa's slightly better efficacy, but considerably higher rates of weight gain. Take a look:

Notice anything weird? The slide data doesn't match the study data.

The impulse is to say Lilly found a way to minimize the weight gain. 10% difference may not seem like much, but it is a reduction of 25% over the published study. Companies kill to get that kind of reduction. But, believe it or not, that's impossible: Lilly is not allowed to exaggerate or lie. The FDA signs off on these materials-- a dozen scientists at Lilly and the FDA have reviewed this slide and the data. They wouldn't be able to get away with fancy spin to drive the numbers down in their promotional materials.

It took me a long time to figure it out: the slide assumes an LOCF analysis (common in psychiatry), while the study uses "weighted generalized estimating analysis"/MMRM. Do you know what the difference is? Exactly.

Because here's the thing: the FDA reviews and signs off on all promotional material, but they do not have any say at all into the actual published study. For all they know it could be written in crayon or sheep's blood. I know I'm going to sound like a broken record, but the weak link in the chain of science isn't Pharma, it's academia.

III.

LOCF-- last observation carried forward-- means that even when a patient drops out of a study, whatever data he did generate stays in. "If it happened, it happened."

Psychiatry studies typically use LOCF, it is the default standard. More importantly: psychiatrists assume LOCF is being used in the study they are (not) reading..

No one knows what "weighted generalized estimating equations" are. Take this study to the nearest psychiatrist, ask him if he knows. If he says he does, smack him in the face with it, he's lying. In fairness, doctors don't expect this kind of a curve ball; and study authors must be aware of their audience. The purpose of the publication-- not the promotional material-- is to inform us. It is to tell us what really happened. They are supposed to make it as easy to understand as possible, and not trick us.

"It's not a trick, we told you right there in the study."

Telling me is not the same as telling me.

Exhibit A:

A post hoc longitudinal mixed-model analysis was performed for mean change from baseline... A spatial power covariance matrix was used to model the correlation between measurements...

Exhibit B: Brown University Psychopharmacology Update didn't notice it either.

Viagra may have good efficacy, but if the results are published in The American Journal Of Geriatrics I don't expect you to have tested it on a sample of 17 year old boys who just watched Megan Fox in anything. And if you did test it in them, you should probably include a picture.

A picture of Megan Fox, for no reason at all

Oh, it's honest: the study authors certainly weren't lying. But everyone must know that no one is going to figure this out on their own, right?

IV.

Someone will inevitably email me to correct me that MMRM is completely legitimate, betting I don't understand clinical trial design and statistics. That would be a sucker's bet.

The authors of the study didn't design a study with an unusual analysis; they designed a perfectly ordinary study, the kind everyone would expect, using LOCF, that they then later decided to analyze differently using something most people have never heard of. You would only know this if you went to the BMS clinical trial registry-- the thing everyone was demanding Pharma do that now no one bothers to use-- and looked it up (138003.pdf), then spent time comparing the two documents. Good luck to the rest of you people who actually have a life.

Or-- and this is sort of the point, sad in its own way but true nonetheless-- you could have just looked at the Lilly slide.
===== ====== ===== The Last Psychiatrist: Why Do Politicians Cheat?
You all are not going to believe this-- the answer is not completely narcissism.

One possible explanation, said Stanley Renshon, a political psychologist at City University of New York: "Narcissism is an occupational hazard for political leaders. You have to have an outsized ambition and an outsized ego to run for office."

or

Fred Greenstein, a Princeton University professor emeritus of politics, suggested adrenaline as the common denominator, saying, "For some individuals, the excitement of illicit sexual activity might feed the same desire" as "the excitement of politics."

or

These are men who love themselves deeply, need to be recognized and relish approval. These are men who adore getting praise and who often are surrounded by swarms of sycophants. These are men who, in some cases, need to exercise power and sometimes can become drunk from it. These are men who think the rules don't apply to them and who think they're untouchable.

These all sound plausible, but only if you don't look too closely at the details of each case. These men had obviously different psychological forces at work in their infidelity.

Simple examples: Mark Sanford appears genuinely to have fallen in love (or something) with "Maria," while Eliot Spitzer and Bill Clinton saw the dalliances as... recreational. So while narcissism may have explained a single individual's cheating, it doesn't apply to all.

Some affairs were homosexual. Sometimes the wife was surprised, sometimes she suspected, and sometimes (as in the case of McGreevey's wife) she was allegedly a participant.

No consistent motivation attributable to "power" or "dominance" or "thrill of the chase" can be generalized here.

Neither is there much to grab onto with the standard variables. Some women are younger, older, good looking and bad looking. There's no relation to length of time married, or number of prior marriages.

There is, however, one important unifying characteristic of political infidelities that makes them very different from the average joe on AshleyMadison.com: everyone knows these guys are going to get caught.

II.

So instead of asking, "why do they cheat?" ask, "why don't they simply not cheat?"

Seriously consider this question. Unless we are positing that these men are all addicted to infidelity, or compelled by genetics or voodoo to make that specific gigantic mistake and not others; a mistake which other people can't empathize with-- "he destroyed his career and marriage-- for her?!?!"-- then they should be able to resist the temptation, if for no other reason than self-preservation.

Neither are these drunken accidents at a snowed in convention hotel. There was no impulsiveness. They had plenty of time to consider their actions. They decided that this was a good idea.

They slowly and methodically planned it, and did it. For them, there is no element of resisting temptation. They didn't do it despite themselves; they did it because, in their mind, this was worth it.

III.

In other words, there must be some other benefit beyond the sex act itself.

An interesting paper explored the reactions to infidelity. As you might expect, men would be more upset by a woman's sexual infidelity and women by a man's emotional infidelity.

However, when men and women are first asked to contemplate their own death, sexual infidelity was even more important to men, and even less important to women:

For men who already place a high value on having sex, being reminded of one's mortality makes the sex even more important.

None of these guys think they are dying, but they do see themselves at the end. You might think being Governor is a major accomplishment, but he sees the next 40 years as all downhill. What's he going to do after Governor? Last July he was meeting with McCain to be VP-- we know how that turned out. His life is over, and he's only 49.

IV.

An identity crisis of sorts kicks in around 40: "for the past forty years I was the guy trying to become something. Now what am I going to be? The guy who was something?"

When your memories outnumber your dreams, you're getting old.

Meanwhile, your wife doesn't particularly want you to grow, or change, or evolve. She wants you status quo. Even innocuous attempts at change are met with bemusement: "oh, God, he suddenly decided he wanted to take up biking, and he bought all this biking equipment..."

But an affair lets you be someone new, and get seen by new eyes. Politicians spend so much energy maintaining a constant public persona. And their family also has a constant perception of them. And now suddenly someone else sees you differently, and you even get to penetrate her...

Having an affair is a creative act. No one leaves an affair saying, "oh God, I feel ten years older." When someone sees you, experiences you, in a different way, you feel more alive. It's all illusory, of course, but that doesn't seem to stop people from feeling it.

V.

If I go to Moldova and have a fling with a woman and choose not to put it on my blog, I'm probably going to get away with it. This is partly because I figure no one is monitoring me, and partly because I had the common sense to go to Moldova where I am absolutely sure no one is monitoring me.

Yet these men take absolutely no precautions against detection.    Why don't they go to Moldova? They don't even take ordinary precautions. Instead, these men are ludicrously indiscreet, clumsy, and careless. They may as well write an op-ed in the Times-- "I will now penetrate this hooker."    Who disappears for days and doesn't even attempt an alibi? Who emails their mistress from their government email account? Who uses airport bathrooms for anything? Who names a boat "Monkey Business?"

Neil Thigpen, a political science professor at South Carolina's Francis Marion University, said that judging from Sanford's behavior, the governor wanted to be caught.
"I almost feel like he did this whole thing with the intention that it would all come out," Thigpen said. "It's like the guy wanted it out. Why did he draw attention to himself in this fashion? Even with rudimentary scrutiny, he should have known something would bring it to a head."

Not quite caught; but if so much of their identity comes from public perception of them, then "getting caught" is external validation that they are still alive, still growing. Cheating wasn't the point: getting caught was the point. It is trying to show the world that you are actually what this new woman thinks you are. It is a form of exhibitionism. It's a four year old: "look what I can do!"

And when they apologize on TV, that isn't analogous to pleading guilty at a criminal trial. It's analogous to releasing a sex tape. "In case there is anyone out there who wasn't aware of what I can do, let me now apologize for it, slowly, over the next few months, in every possible media outlet I can use."

------------

This is unrelated to the above, and I have no idea what to make of it, but I made an odd discovery about the famous political sex scandals since Clinton:

SC Governor Mark Sanford (R) 5/28/60

Nevada Senator John Ensign (R) 3/25/58

Idaho Senator Larry Craig (R) airport bathroom nonsense. 5/28/60

Louisiana Senator David Vitter (sigh, R) admits to having been involved with an escort service. 5/3/61

Senator John Edwards (phew, D) 6/10/53

Gov. Eliot Spitzer (D) 6/10/59

Gov. David Paterson (D) 5/20/54

Gov. Jim McGreevey (D) 8/6/57

Bill Clinton (D) 8/19/46

Newt Gingrich (R) 6/17/43

Rudy Guiliani (R) 5/28/44

Louisiana Rep. Bob Livingston 4/30/43

OK Rep. Gary Condit 4/21/48

All of these men were born in late spring-summer. No fall or winter births? Any astrologers want to tell me why 8/13 are Geminis?

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===== ====== ===== The Last Psychiatrist: I Win Again

Seems like some people liked my Iraq post.

Other people hated it, of course, keeping in check my gigantic ego. Thanks!

6/5/07 Addendum: But wait: PsyBlog has decided I have the "Best Psychiatrist's Blog." Take that, Lisa's beliefs!

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===== ====== ===== The Last Psychiatrist: What Political Propaganda Looks Like

This is what a subscription to JAMA gets you:
from the abstract:
RESULTS: Among the 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Among the 82 women who maintained their medication throughout their pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication. Women who discontinued medication relapsed significantly more frequently over the course of their pregnancy compared with women who maintained their medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P<.001). CONCLUSIONS: Pregnancy is not "protective" with respect to risk of relapse of major depression. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation.
Read it again. What's the message they are trying to communicate?
The study found that pregnancy is not protective, and stopping your meds during pregnancy raises the risk of relapse. Any other way to interpret this abstract? Am I putting words in their mouths?
I read the entire article, with familiar horror. This was a naturalistic study that followed 201 women with MDD and their medication dosages and saw what happened. That this study had nothing to do with the "protective effect of pregnancy" is right now a secondary issue. The real problem is that the actual study says something very different than the Conclusions:

The study did find that more people relapsed if they stopped their medications. But it also found that more people relapsed if they increased their medications.
Exactly how were you to know this if you only read the abstract?
Don't you think that might have been important? Tthe medication changes themselves are not the cause of the relapse-- how could both stopping them and raising them both be bad?-- but are logically explained as representing something else.

The Conclusions should have read:
Conclusions: Taken together, these findings suggest that pregnant women who are stable (on medication) tend not to relapse, but those who are unstable (and need med changes or who go off them) relapse at higher rates.
The authors do address, slightly, this odd finding-- on the last page. But so what? Only liars read the last page. What makes this misrepresentation so egregious that it is near unforgivable in a journal of JAMA's arbitrary status is that they and we know doctors are not reading these studies from start to finish; for the most part, we skim over the abstracts. So we're going to skim over this abstract, it supports our existing prejudices so we don't give it a second thought, and go on with our deluded lives.
So to write the abstract this way is absolutely volitional, and absolutely misleading. The problem is not with the study, which was excellent, but with the presentation of the findings, which is psychiatric propaganda.
I would demand my subscription to JAMA be cancelled immediately if I had one in the first place.
---
But this isn't really the disturbing part.
What's really sad is that I am, apparently, the only one who noticed this. None of the three Letters To The Editor about this article complained. One of the three letters did complain, but not about the article-- rather about the authors' ties to drug companies. Yes, that again. That's what passes for ccritical thought nowadays. That's now the default moral high ground soundbite of bitter doctors, akin to "the war is just about Halliburton" or some other half-thought deduced from two hours of the Colbert Report and the table of contents of the New York Review of Books.
That's the problem. We're not critical of our fundamental principles. So we attack windmills. We doctors are conditioned (yes, conditioned) to find Pharma bias everywhere, and never to see-- so that we don't have to see-- the real bias in the way we have set up psychiatry. It's the same reason we spend so much time on statistics. Pharma and statistics are witches in The Crucible.
The bias isn't Pharma related. It's much more fundamental. What's at issue here is the approach, the worldview of the authors and psychiatrists everywhere.   They are seeking to support the notion that antidepressants work and prevent relapse-- not even because that's what they believe, but because that's what psychiatry is. They are not asking a theoretical question and impartially looking for the truth; they're unconsciously trying to validate their existence. So they see what they want to see, and anything that isn't obviously in support of these postulates, this paradigm, is cursorily dismissed-- or is altered to mean something else. This is important: they're not hiding data, they just interpret it with the only paradigm they have.
Blaming Pharma is easy because it seems obvious-- money buys truth-- but also protects the blamer from needing to perform any actual critical thought, any internal audits of their prejudices. So what if Pharma bought those doctors start to finish? You still need to read the study and figure out how the buying altered the data, if it did. But that would be work.

10/30/06 Addendum: I sent a modified (i.e. nicer) version of this as a Letter to JAMA. It was rejected in less than a day.

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===== ====== ===== The Last Psychiatrist: Jay-Z Calls The Next Market Move

That's a still from Jay-Z's video, "Blue Magic." The significance of the shot should be obvious to anyone, whether or not they trade currencies. Why it's not obvious is the real question.

1. Friend of mine comes over Monday night and says, "hey, I know you own Google-- I'm thinking of buying it. And what about Euros?"

2. Did you know 7 countries are considering abandoning the U.S. Dollar?

3. 11 out of 12 experts vehemently believe the dollar is headed for collapse, or at least much further fall. None of them tempered their opinion, or qualified it. “The dollar has further room to fall regardless of incoming US data.” “The dollar will keep falling in the near term no matter what.”

4. and, of course, Jay-Z uses euros in his video. And Gisele Bundchen wants to be paid in euros, not dollars.

And everyone is convinced that if even Gisele and Jay-Z are converting to euros, then that's it for the dollar.

Well, not exactly.

I have never been in a room, on the side of a trade, or in an argument when everyone- everyone-- was in agreement about something, and that something turned out to be correct. The more people convinced of a proposition, of a certain mindset, the greater the likelihood that they are wrong.

Why does anyone think that Jay-Z knows when it's time to covert to euros? But, to a man, everyone commenting on the blog that discusses the Jay-Z/euro link is bearish on the dollar. I defy you to find anyone who is bullish on the U.S. dollar. Everyone thinks it goes lower. (Interestingly, except Alan Greenspan.)

People like Jay-Z, and everyone else in a situation of unanimous agreement, are what is known as contrarian indicators. So are cover stories in magazines. When Time puts the iphone on the cover, you sell Apple.

Not forever; just until they stop talking about it.

When my friend, who knows nothing beyond the basics about trading stocks, wants to buy GOOG, then you sell-- until he says, "no way am I touching GOOG."

Here's why contrarian indicators are so reliable. Most people say it is because "by the time" Jay-Z knows about an economic trend, the trend is over. Implying that he is not smart enough to perceive the trend early. That's not exactly correct. It's not that he is late to a trend; it is that he is the last money into a trend. For whatever reason-- lack of knowledge, lack of motivation, resources (including opening a trading account, etc) he puts his money in later than others. But once he puts his money in, then there is no more money to put in. If everyone has bought-- and everyone agrees on the rightness of their position-- there's no more money to put in. So the trend ends.

This is true about everything, not just money. When every psychiatrist "knows" an antiepileptic mood stabilizer is the first line for bipolar in the absence of any evidence for this primacy, then you know it soon won't be. When everyone "knows" a girl is a slut; when everyone "knows" X policy will do Y things; all these things should be tells that the opposite will be true.

Not always because they were wrong, mind you, but because they cause it to be wrong. That's the key. It's not that Jay-Z is wrong about the dollar; it's that by investing in euros he causes a top in the euro.

I'm on record: I call a bottom.

(long gold, long oils, brk and aapl-- and dollars. And I'm not touching the euro.)

===== ====== ===== The Last Psychiatrist: Jay-Z Gives Ten Reasons Why Pop Culture Authenticity Is Real Only If It's Fake On Purpose
"But that title doesn't even make sense!" Exactly. Yet here you are.

I watched Jay-Z's video Death of Autotune, in which he disparages guys like T-Pain for using autotune (electronic modulation of voice) and generally for being pop "z100" music, and not authentic "hot 97" black rap music.

No lyin, your niggas' jeans too tight
Your colors too bright, your voice too light...

You niggas singin too much,
Get back to rap you T-Pain'n too much
I'm a multi-millionaire
So how is it I'm still the hardest nigga here?
I don't be in the project hallway
Talkin' bout how i be in the project all day
That sounds stupid to me,
If you a gangsta, this is how you prove it to me
Yeah, just get violent
This is death of autotune, moment of silence

Ok, calling someone less authentic than you is a standard combat maneuver. Nothing new there.

So if Jay-Z wants to depict his authenticity, to show how and raw, honest, legitimate he is in comparison to the other "niggas" he would do this by placing himself in authentic, legitimate, true to his roots situations and settings.

Here's where it got interesting.

Based on the video, Jay-Z is, deep down, a guy who dines alone in Italian restaurants.

who pays his respects to the chef-- or the other way around--

etc, for more pics see any episode of The Sopranos.

My first reaction was that maybe Jay-Z had had a stroke. Is he aware that he is not actually Italian?

After this meal, he goes to the back of the restaurant with other legitimate Italians like Harvey Keitel and, believe it or not:

Yes this is an all night poker game, yes it is played in the stockroom of the restaurant, yes they are sharing a bottle of wine and some pasta, yes that's an olive oil sign, yes those are hundred dollar bills ("this ain't a strip club"), yes they are all in suits, and no he's not kidding.

In a video about getting back to basics and authenticity, he chooses an entire persona that couldn't be less authentic. What's crazy about this is that music today tries to be more urban, more street, more black-- things that he authentically is already, he's technically won his argument just by waking up in the morning-- and yet he instead picks a character that is utterly unrealistic, waves it in our face and and says, "this is me, keeping it real."

II.

It would be easy to just say he's an idiot, but this is a man who is hypersuccessful precisely because he can manipulate imagery to connect to his audience. He may be Italian, but he's no dummy.

The problem Jay-Z faces is that because all anyone knows about him is images, he has no way of signaling authenticity. If he's shows himself in the projects or on a yacht or behind bars or on the moon, no one can know if it's really him or if it's hype. Maybe he owns a spaceship, who knows?

So Jay-Z chooses to signal his authenticity not with authenticity, but with an already established symbol of authenticity: because otherwise, how would we know he was being authentic? Italian= authentic, traditional; black = masculine, strong. He already has the black part. And it doesn't matter if the other actors are real Italians either, as long as they symbolize "Italian" which symbolizes "authentic". Hence Harvey Keitel.

There's another major benefit from choosing a completely unrealistic symbol of authenticity. Note that his audience isn't Italian mobsters or "kids in the hustle;" there aren't enough of them. His audience is regular people, black and white, for whom authentic isn't "being yourself" or "true to where you came from" because for those regular people, that would be unbearably boring. For them, authentic has to mean loyalty to the persona you made up. This video isn't about Jay-Z's authenticity, it's about letting you choose your own authenticity.

He does this not by being Italian-- obviously no one believes he plays back room poker at Rao's; but by reducing "Italian" to a symbol or commodity that can be acquired or put on, like an outfit, in order to convey information to others. In other words, he's using Italian as a brand. He is more authentic branded as a TV Italian than if he was actually just himself. Read that last sentence again.

That's how you build the Matrix.

III.

This ain't for Z100... this is for Hot 97...
That may be true; and that may convey the impression that his music/this song is elite, not for everyone, it has some reserved status and/or artistic integrity, but it is not in reality any more difficult to get it from the free radio station Hot 97 than from the other free station Z100. In other words, it's not really elite, it's just branded as elite.

This is anti-autotune, death of the ringtone
This ain't for itunes, this ain't for sing-along
Of course it is: here's a ring tone, here it is on itunes, here's an MP3 on Amazon, and I fully expect to see lots of guys performing it terribly through open car windows... but that's the draw. That's the business smarts of Jay-Z. Brand it, make it seem elite, make it an aspirational product-- but make it easily available, everywhere. I'm surprised he hasn't thought of selling scratchy, barely audible free underground bootleg copies of the song for $24.99.

That's Trading Up again (and I should tell you that book doesn't describe it as a social critique but in all earnestness). That's the two parts of profiting from effective branding. You have to make it seem elite and hidden, but make it easy/affordable to access it.   Then-- and this is the key-- the consumer has to be able to show others that they've accessed it: that's the only way other people are going to know who they are pretending to be.

IV.

This is how kids operate, but it is also how adults-- who don't realize they are adults but still think they're kids-- act as well. I hardly need to tell you what this phenomenon is called.

Here's a random coincidence for you: there's a book called From Jay-Z To Jesus, and it has this sentence on the back:

Acknowledging that young adulthood now encompasses ages 18-39...
I'm shaking my head because they're right.

V.

Guess what this picture is all about:

This past July there was a panel called "Raising Him Alone," part of the larger conference "Saving Our Sons."

Don't miss Saving Our Sons! This free community event is open to everyone who is concerned about the educational crisis facing young men of color and wants to make a difference! Learn strategies for helping our young men achieve academic, professional, and social success. This event is for EVERYONE - parents, grandparents, educators, mentors and concerned citizens because real change can only happen when an entire community is informed and engaged.

It's in the Bronx, feel free to guess at the audience. This will include a

a panel discussion featuring prominent women who have successfully raised their sons alone.

There's two ways to make this work. One way is to find women who have raised successful black men, e.g. doctors, teachers, etc, to offer advice about how to keep your son focused on boring academics. But no, it features the mothers of rappers.

Well, ok. The other way to go about it is to find mothers who, like the audience, had to raise their kids in the same adverse circumstances, e.g. it's hard to be a black single mom raising a son in the inner city. Drugs, guns-- all of the stuff Jay-Z used to talk about before he bought a restaurant. However, there's a bit of a problem with their panelists, see if you can guess what it is:

Dr. Mahalia A. Hines (mother of rapper and actor Common), Dr. Brenda Greene (mother of rapper and activist Talib Kweli) and Sheron Smith (mother of Grammy nominated actor and rapper Mos Def.)

Do these women have anything in common with their audience?   Dr. Hines is nominally a "single black mother"-- the words are accurate-- but she's also a woman with a Ph.D. who sent her kid to private school. Both of Kweli's parents are college professors. But since their sons are pretending to be inner city youth forced to choose between rapping or dealing, they are therefore mothers of inner city youth almost gone bad, even though they're not. But no sane person is going to question the 'hood cred of the mother of Common.

The tragedy of this conference is that Dr. Hines et al have a real and valuable contribution to make: how they managed, as black single mothers, to continue their own education and professions-- but that's a conference no one would attend. But shoudn't the conference organizers have pushed for it anyway, for them to be role models in that way? Instead of letting the women be who they are, they turned them into symbols of something that they aren't to no benefit of the community at all.

And if this is a conference about educating black kids, then isn't Ph.D. mother raising a rapper son the exact opposite of what you want? Oh, is that wrong to say? Imagine Eminem's mom coming to speak to white parents about the importance of educating children.

The unfortunate message of this program is the importance of raising sons to be famous (i.e. how they reflect on you) is more important than the example you set for your kids (how you reflect on them.)

VI.

"What's with white kids today? Why are they pretending to be black?"

They're not, they're pretending to be masculine. You may not believe this, but white boys/men have no symbol of masculinity or toughness-- or of sexual power-- that they can brand themselves with. The fictional white tough guys are either "black" or are flawed: strong in one way but weak in some other (broken men, depressed, drinkers, etc.) They have to pull it together to be tough. And white tough guy/heroes cry a lot. What's up with that?

If a white kid wants to project masculine energy, he better figure out a way to be black and make it look legitimate. Fortunately, Eminem and others have done the hard work of branding blackness, reducing it from something you are to something you adopt, turning it into apparel to wear when you need to convey information. Now it's credible that white guys can be black without actually having to be black. Thanks.

The odd problem that this presents is that though black kids in the inner city may legitimately need to project toughness, the white kids'-- and many black kids'-- accumulation of toughness brands is actually useless. However, if you brand yourself long enough you begin to believe it. At the expense of applying to graduate school and possibly your life.

They're going to find themselves one day, full of anger and resentment and rage at absolutely nothing at all-- and middle aged.

How are the 40 year olds who got caught up in the east coast/west coast battles faring today? Was it worth it? It was for rappers, I guess.

VII.

Back to Jay-Z. He's probably in no danger of being deported to Sicily. But he's definitely "drawn a line in the sand" (his words) about Autotune and rap in general.

Well, maybe. Or maybe he realized, after making an album's worth of songs that did use autotune, that it was becoming overused and hack, and so he dumped those songs, made an anti-autone song, and prepared to pretend to be the one who caused the demise that was coming anyway.

Or maybe he's creating a fake controversy that he himself doesn't believe in, but that his audience can use to communicate to other people who they want to be: "I'm against autotune, I'm street and authentic;" "I'm for autotune, I'm artistic and fun." Fake divisions that can be used as brands.

In that way, both he and the Autotune guys can benefit.

Here's a picture of Jay-Z performing Death of Autotune this summer:

See that guy next to him? That's T-Pain.

And he looks authentically pissed.

----

Clarification on masculinity here.

And then the VMAs.

----

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Jay-Z Is A Genius

Q: What do the three red lines mean? A: Wrong.

The three red lines mean "3," as in "Blueprint 3." Ok, so why aren't they blue, like Blueprint? You should now start to suspect that what the lines mean isn't the right question (the medium is the meaning.) The question is, why are they there?

Look at the cover again. Making the rounds is this video, it is the making of the cover of Jay-Z's new album, Blueprint 3. Read that sentence again and reflect before you watch the video.

It shows the musical instruments being stacked, the sculpture being constructed. Then, at the end, the designers apply red color onto the sculpture itself.

So while it looks the lines were digitally added, and it would have been much easier to digitally add them, they're actually on the instruments. They're actually real.

II.

Some have seen resemblances/sampling from such pictures as these:

(From idolator)

or this one:

The "E" is the most relevant, as it was the "inspiration" for the cover. By inspiration, I mean it was created and shot by the same photographer, Dan Tobin Smith.

But as you saw in the video, this cover is not a "sampled" version of those pictures, it's not cut, paste, and recolor. It may look like, be inspired by, those others but-- just like he doesn't sample "hey hey hey, good bye" but actually sings it-- everything you see and hear is strictly Jay-Z. Jay-Z is saying, I'm a real artist. I don't take shortcuts. This is anti-Photoshop, death of the thumbnail. This image was entirely assembled, it took a long time, it took a lot of work. Even the red lines are real, not CGI.

So now the point of releasing a "Making of The Cover" video becomes clear: it's to show you how authentic he is.

The red lines are there to lead you to discover that they are actually there.

III.

from Axel Peemoeller

ettf.net

Look closely/take my word for it, the colors are not painted/photoshopped onto the photograph, but are actually painted into the walls/ground/railings/etc. Cool, huh? It's alright, you're allowed to like it, you don't have to be metafilter smug all the time.

While this style of art has been around for centuries, today it carries a different implications: it is always conscious of the existence of CGI. Whatever else the art says or is, it is also saying, "it looks like CGI, but it isn't." Usually CGI is used to fake reality, but in this case the very point of the realism is to make you think it's CGI, so that you can be awed by the fact that it isn't. Its authenticity is reinforced by the work you have to do to discover it. "Holy crap, that's real!"

To repeat: this is something real that is designed to look fake.

IV.

What does it say, however, that this technique is regularly found in commercial art?

It says the same as Jay-Z wants it to say: "if this packaging art is real, then for sure the product inside is completely real. And the artist is 110% authentic."

But this kind of authenticity is the most manipulative kind of fakery, because "the illusion" masking the reality only occurs if seen from one specific perspective, chosen by them.

From any other perspectives decided by them, you don't see the illusion.

The illusion masking the authenticity-- the red lines that look CG'd, the illusion you're supposed to work through to appreciate the authenticity even more-- never materializes. All you're left with is the one level of real, and it is real boring.

Here's what is absolutely vital to understand: for the commercial part of the art to be effective, not everyone can be in on the trick. You need some people who say, "what's the big deal? Some idiot painted some colors on the walls. I don't get it." You need them so that the people who see it from the right perspective are motivated to dig deeper. "Wait, are you serious?!" You've created us vs. them. You've branded it.

Our postmodern society thinks it is clever for always looking deeper, for knowing there are always two levels. It "knows" appearances are lies, it knows the real truth is beneath the appearances. It tries to uncover.

We're not as smart as they are. Commercial art, Jay-Z, all of TV, all of the news, reverse the order of the levels. They hide the lie they want to tell you one level deeper, let you dig for it. And when you find it, after all the work, you accept that it must be the truth. "Backstage", "behind the scenes", "the making of", "investigative reporter", "obtained documents", "leaked"-- now we're getting to the truth!

You're not.

Commercial art of this kind works because it is able to control the perspective. You think you're making your own judgment about what you see with your own eyes, but it has already been decided how you will see it, why you will see it, in what context... so that you "uncover" only what it wants you to uncover.

V.

If you can't understand the emo kid with black lipstick, or the white kid in baggy jeans flashing gang signs, or Jay-Z pretending to be Italian, or any of a billion different obviously fake identities-- and if you can't understand why, despite the obviousness of the fakery, some girls who are not complete idiots fall for it-- it's because you're not seeing his fake identity from the right perspective. He's showing the fake symbols of something (toughness, intellect, etc) so that you try to look deeper, and whoever responds to what those symbols mean (toughness, intellect, etc) will do so.

He's dressing himself in red lines, tempting you to see if they're real or not.

If you are tempted to look more deeply (if you're watching it, it's for you)-- like the smitten girl does-- you'd see this appearance first, then through it: "if you got to know him, you'd see he's really a...!" And then you'd pat yourself on the back for having intellectual courage to not judge by appearances! But you've been fooled by the commercial art illusion, thinking that because you saw through the illusion, therefore the deeper level must be authentic.

Those who don't come to it from exactly the right perspective are infuriated, "this guy is a douchebag!" You think you see something more real than she does, but you aren't supposed to see more deeply-- she is. You are supposed to be infuriated-- that's why she looks more deeply. She doesn't like him, she likes what liking him says about her. She likes what your hating him says about her.

"How the hell come she can't see through this poser?" She does see through it, you don't. She sees something fake, then something "real" underneath, and falls for him; you see something fake, stop there, and hate him.

That's exactly what he wanted, both times.

That's what Jay-Z wants, too.

We are all commercial art.

-----

More on Jay-Z 1 2

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===== ====== ===== The Last Psychiatrist: J Crew Ad Promotes Something That Some Call "Transgenderism"

I love how natural she looks

The kid is Beckett, the son of the woman in the photo. Look, he's wearing pink.

Media commentator Erin Brown of the Media Research Center also had strong views, calling it 'blatant propaganda celebrating transgendered children.

'J Crew, known for its tasteful and modest clothing, apparently does not mind exploiting Beckett behind the facade of liberal, transgendered identity politics.'

Before you jump in with your own ideas, ask yourself a question with a very obvious answer: do you think that photo is real?

People are arguing over it like it's hidden camera footage of this woman's house. Do you think this scene wasn't staged? How many takes did it require?

Look at the ad carefully. What is it selling?

You probably think it's the shirt, but there are two products there: the shirt and the nail polish.

Look carefully at that nail polish, neon pink. It doesn't exist, not in that exact color, anyway. The color's name is "Short Shorts," and thanks to the magic of Photoshop it doesn't have to look like this:

Look at those crayons. Those are artificially enhanced colors.

This isn't to say it isn't trying to promote transgenderism, or it is; but as an ad it's telling you something about you vs. the products so we may as well listen.

II.

It's Saturday, you don't have to dress up for work. Yay! Hold on, that doesn't mean you're allowed not to dress up. No sweatpants for you.

The woman in the ad is attractive but not in a vulgar, sexual way. Supremely comfortable with herself, her life. It seems effortless. And she's the president of J Crew. And she has her son with her. She's the product. The image. You don't like the polish, fine, J Crew has other stuff to make you into her. In other words, she is you, the aspirational you. The kind of you that can say this:

She doesn't put her kids in front of the TV so she can get a minute to poop. She doesn't have to.

She's the product, all those things around her are accessories. The polish is an accessory, and its color has been enhanced to better broadcast the message. The kid is an accessory, and he's been enhanced to broadcast the message. Clean, vibrant, simple, alive, happy, fun.

What's going on in the ad? Now it's 11:30 (Beckett sleeps in on the weekends, of course) and the art project is done and the coffee (french press) is so good it doesn't need milk or sugar. Giggle. Lighthearted fun ensues, and the boy gets his toenails painted. Now, obviously, he's a boy and he's not the kind of boy to get his nails painted pink, it was all in spontaneous fun. But it's not like anyone's watching, it's in a safe environment, where you can do whatever you want and no one makes assumptions. Dad's not there. She can just throw her hair in a bun and be the kind of beautiful women like. "I love Anne Hathaway." Me, too.

How much you wanna bet her nails aren't painted neon?

Of course not, that's not her style. She's not the kind of successful and stylish mom who would wear neon pink, either, but sometimes it's fun to play. HA!   That is fun. So why even buy the neon and the orange behind it if you're not going to wear it out? Oh, because it's fun, frivolous, like the crayons. The nail polish is crayons. And because, precisely, if you wear it, it doesn't mean anything.

III.

"But surely J Crew must have known this photo would be controversial?" Ummm, duh.

And controversy is publicity and blah blah, marketing 101. But the controversy serves to establish who you are not. First, if you're offended, you're probably not a woman. Do you see any men in the ad? It depicts a safe, comforting place for women. He's not home.

Or you're not an attractive woman. Erin Brown of the Media Research Center might be a supermodel but she sounds ugly, doesn't she? Or old. Yuck. Nothing clean, simple, or vibrant about that. Her Saturday's probably involved planned defecations. That's not you, the J Crew consumer.

"But don't you always say "if you're watching it, it's for you." Why is Erin Brown watching it? Because the ad gives her a way of defining herself. Everybody wins.

"But now there's a possibility the kid may become gay, or transgendered." The word you focused on is transgendered, the word J Crew wants you to focus on is possibilities. The kid with the painted nails is young, doing something out of the norm. He embodies possibilities, so J Crew embodies possibilities.

If there is anything "bad" about this ad, it isn't the transgenderism, but the Desire. You are different from her, but you desire to be her.

The problem is that your desire doesn't know the difference between real you and the aspirational you, and it relentlessly pursues the Symbolic. Desire is never satisfied, it is never fulfilled.

That's what J Crew is banking on.

===== ====== ===== The Last Psychiatrist: Jezebel Proves Scott Adams Is Right

(note to lawyers: I made this, not Scott Adams, and falls under parody, so bite me.)

Scott Adams, Dilbert creator, sparked a feminist controversy of sorts, and then he asked for feedback from:

Judge

Psychologist (professional)

Logic Professor

Scientist

etc, by which he meant: men.

And he got a lot of feedback

If you already know the controversy, skip right to III.

II.

Now consider human males... Powerful men have been behaving badly, e.g. tweeting, raping, cheating... The current view of such things is that the men are to blame for their own bad behavior. That seems right. Obviously we shouldn't blame the victims....

The part that interests me is that society is organized in such a way that the natural instincts of men are shameful and criminal while the natural instincts of women are mostly legal and acceptable... Whose fault is that? Do you blame the baby who didn't ask to be born male? Or do you blame the society that brought him into the world, all round-pegged and turgid, and said, "Here's your square hole"?
That's Scott Adams, writing the not original "men are oppressed in a female controlled society" argument. Men would naturally be raping and pillaging and wearing horn helmets, but the world's not set up that way anymore, and its not set up that way by women. They have all the power, and they have restricted men from acting on their penile instincts.
Here's is the prototypical "feminist" response/censorship petition, from Change.org:
Scott Adams, has written a blog insinuating that the act of a man raping a woman is a natural instinct and that society is to blame for these things, not the man who committed the rape.

Which isn't what he said, but, whatever.

III.

Let's start with Jezebel, who, despite having the moral high ground and being staffed by people who are paid to practice writing about this sort of thing, completely botch it. If you want to increase understanding or bring people together, do not do anything close to what Jezebel does here.
Jezebel's response is typical of the way Americans argue politics and social theory: straw man and appeal to authority. It's obvious the writer finds Adams's blog offensive, and I will accept that she wants the world to be a better place, but no where does she make even an attempt to articulate why she finds it offensive. After she quotes Adams, she writes:

Wow. Trying to make it sound like your argument falls under the category of "gender theory" while saying that "boys" are pretty much designed to be rapists and we'd better get used to it is...I don't even know what it is anymore.

And nothing else. There are other words, sure, but just like the above none of them refute his point, they're just ad hominem padding, "he's a jerk for thinking it." I'm sure your regular readers agree, but for the dummies among us, can you perhaps explain why?

Which leads me to suspect that she doesn't actually know why it's wrong, only that it is wrong. And to escape detection, she offers deliberate misreadings like "he's justifying rape" so that she can follow it with "'Nuff said."

Here's the very practical problem: Adams is not alone in thinking that women are running the culture and men are being emasculated. If Jezebel's goal is simply to insult him, fine, but tremendously boring. But if their goal was also to promote a vision of social equality, they've done the opposite. All they did was bully and insult him. "You're a jerk, accept it! I said accept it!" But that power is precisely what he's complaining about. So not only does it not convince Adams (or anyone else) what he's saying is wrong, it confirms for him he is right about them.

IV.

Salon pretended to offer a reasoned response. Three paragraphs of fluff, then in the fourth paragraph she begins:

There are two important rebuttals to be made here.
Ok, finally, please proceed:

First and foremost: thanks for all the gags about casual Friday, but Scott Adams sounds like he's lost his freaking marbles.

Hmm, interesting and unexpected point. And second?

Second, as a colleague pointed out recently, remember the old sexist argument that women weren't qualified for positions of power because their lady hormones would make them act all crazy and emotional?...You don't hear that one so much anymore, do you?

Adams, in contrast, represents a different extreme -- and extremely lunkheaded -- version of an alternate line of sexist thought. And in his own clumsy way, he articulates something many of us have heard repeatedly over the course of our lives, an argument that boils down to boys being boys. Left to their own devices, men apparently would just go about raping and pillaging all the livelong day, with occasional breaks for grilling and watching ESPN. They're just being men, and doggone it if this pesky thing called civilization keeps getting in the way.
That's not a rebuttal, that's unfunny sophistry. She's basically saying, "not all men are rapists." Again, no one disagrees with that; but the more nuanced reworking of Adams's arguments is whether civilization is the only factor that prevents humans from falling into violent anarchy. After the fallout settles, should we should expect more rapes and murders, or the same number? That's a very interesting question, one that goes to the heart of the justice system vs. poverty.

But rather than have that discussion, Salon merely states, as self-evident, that Adams is a lunatic.

That, in a backwards and poorly articulated way, is Adams's point. Why is he required to justify and clarify and hedge and explain, yet Jezebel and Salon can make it axiomatic that he's wrong? Because they control society?

( made by me, not Scott Adams)

Jezebel and Salon have utterly failed to convince anyone who was not already convinced that Adams is wrong; and have reinforced to Adams, et al, that women are running the culture. If you want to swing back at me that it's not Jezebel and Salon's job to change people's thinking, fine, but then what the hell are people doing reading Jezebel and Salon?

It's ===== ====== ===== The Last Psychiatrist: Joe Paterno Fired For A Crime He Didn't Commit

dressing for the big game

As background for the German and Danish readers who are too busy trying to determine if come Monday morning milk will be priced in marks and/or krone, over in America everyone's gone bananas because, allegedly, a Penn State football coach named Jerry Sandusky was molesting little kids. One day an assistant accidentally stumbled upon Sandusky "anally raping" a 10 year old boy in the locker room showers, so he went home, took a nap, and the next day told the head coach Joe Paterno what he saw. What Paterno did next is subject to some debate, but it seems to fall within the broad category of "nothing," which he then did spectacularly for the next 11 years.

Then two days ago riots erupted on Penn State's campus, the kind with pepper spray and armored police, because Joe Paterno was... fired. I think that means they wanted him to stay, but my eyes won't let me believe it.

OccupyWallSt: no violence. Penn State: violence. Americans are idiots.

I.

Here's a good place to start: if Joe Paterno wasn't just a coach but a Catholic archbishop he'd be facing the International Criminal Court, and if he was a hedge fund trader someone would have killed him twice. This tells me that who he is matters way more to people than what he's done, which is almost always an alarm to flip over the couch and click off the safety.

Here's the generational problem, and what's significant about it isn't so much that it didn't happen but that no one has even thought to mention it: the reason Paterno had to be fired is because if he stayed, if he and the administration thought this was surmountable, then it would have put the football players in the extremely uncomfortable position of having to make the ethical decision themselves. "Do I want to keep playing for an organization that hides this kind of thing?" That's a heavy question to ask a 20 year old. These players are college kids, which means that what is at stake in making this choice is their entire futures, whereas what is at stake for Paterno and the school is their legacy. Does some defensive end have to consider throwing away his entire possible career just to make the choice that his elders should have made for him? The answer is yes, but it is way unfair of the rest of us to saddle him with it.

Notwithstanding that the future is demonstrably more valuable than the past, forgetting about that-- it is the responsibility of the older generation to take the bullet so that the younger generation has a chance. "I don't know who the hell spilled all these banana peels and ball bearings, " says Mr. Expanding Waistline And Declining Penile Tumescence, "but I got to clean it up so the kids don't trip over it."

This is why CEOs step down and generals resign, it isn't simply that "they are ultimately responsible" but that it is their job is to throw themselves on the grenade so that the area is cleared for everyone else, and if your CEO or general or father isn't willing to do that, then you don't actually have a CEO or general or father, you have a politician. Enjoy your democracy.

II.

I'm somewhat hesitant to admit that the only thing I know about college football is college cheerleaders, and if you think that makes me less of a man I'll patiently listen to you concoct some explanation. But thanks to the Fourth Estate I now know who Paterno is, how revered he is, and what kind of person is doing the revering: this idiot on the top of a news van jumping in front of a cardboard cut out of Joe Paterno doing exactly what he did when he was told about the anal sex:

I'd like to draw your attention to three things, first, that wildman is standing on a van that is laying unnaturally sideways, second that there are seven hundred and fifty thousand people cheering him on, and third that he is white. That last bit is fortunate because it avoids misunderstanding when I say that he looks like a chimpanzee. And moves like one. But I'd also have to admit that later that night some poor chick from Delta Gamma was on the receiving end of that simian's semen, and she loved it.

Note that while he is probably just a guy standing on a news van, he has been co-opted by the media Semioti-Matic and transformed into a symbol of primitive sexuality and moral idiocy for which he has no recourse or rebuttal. He may in fact be an idiot with a big penis, all of my intuition tells me he is an idiot with a big penis, but who the hell knows? The moment he got put on TV he became an image slave. The media can do what they want with him, and they have.

But surely not all students at Penn State are so unsympathetic to the anal rape of children?

Ah, there they are, couldn't get bus fare to NYC, I guess. Hmmmmmmmmmmmm, maybe this is the rum talking, but anyone else see heptuplets? So it's not just me. The media has now successfully changed the narrative from "somethingsomethingsomething anal rape" to a sports analogy of two opposing teams: Big Dick vs. Hippie Chick. Now it is so easy for me to pick a side, thank you Jesus, a side which has nothing to do with child molestation and everything to do with which of these two groups I hate more.

I would be drunk if I did not point out that just as the media symbol for the collapse of public order is looting-- i.e. the opposite of shopping, the media symbol for a collapse of civil society is the destruction of a media news van.

Show me some broken windows or broken heads and I will wait to be told who is to blame, but anyone who attacks the media is self-evidently a degenerate. The odd thing is that while the media are supposed to be impartial and invisible, the most active in terms of agenda, framing, and activity, is that very media. Their specific function at that riot is to make money, and they're surprised they became a target? If you start a riot, the very first thing you should flip over is the news van. Just don't then stand on it.

III.

I had hoped that the younger generation was going to have better priorities than their highly narcissistic elders, i.e. Sandusky and Paterno and the excellent men and women of the Board 2002-2011, but it doesn't look good. It looks real bad, in fact. What I see is an up and coming generation unable to weigh societal goods, let alone moral equivalences, almost entirely because they have to play Nebraska today. Which scares me to believe that 2012-2035 will be a repeat of 1978-2001. I hope I'm wrong. If you see them bring back pantyhose, I wasn't.

And there's this, and again, I don't know much about football, but I do know a lot about human motivation: If Jerry Sandusky was indeed having anal sex with a 10 year old in the Penn State locker room showers, where anyone could stumble upon him, then it is impossible to imagine he hadn't already done it there before. He felt safe doing it. At Penn State. In the locker room.

If this was any other organization but college football, they would have detonated it faster than Enron. But since no one likes anyone that much, his not being immediately imprisoned requires some explanation other than "well, Sandusky saved me back in 'Nam, so I owed him", and all of them, every single one, is going to involve some version of the phrase "institutionalization of corruption." The only open question is how big you thing the word "institution" is, campus size or national size. When you wake up tomorrow to the unbelievable realization that the Zegna suits in Wall Street are the least corrupt of your generation, remember that the alarm had already been sounded if you had only paused to hear it. Flip over the couch and click off the safety. None of you are safe.

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===== ====== ===== The Last Psychiatrist: Judge Beats His Daughter

oops

A video from 2004 shows a Texas judge beating his daughter with a belt, and America acts like it's surprised those words are in the same sentence.

Well that was unpleasant.
There's no point in saying what has already been said 678418 times, so let's do something else. BTW, why are all the "Related Videos" MMA clips?

II.

First, let's double back on our souls. If you want to learn why you think whatever it is you think, strip away existing context and force it into a new one and see what happens. In this case, assume this video is a fake.
Which is surprisingly easy to do: the dialogue is terrible-- stock phrases probably indicative of narcissistic rage (lines appropriate to his movie) but also of amateur screenwriting, and though the hits are real plenty of actresses would be willing to take them if the movie was going to open during Oscar season.
So now your reaction does not have the luxury of pretending it is based on actual events; those feelings are exclusively inside you. So, are you feeling empathy for her, or rage against him?

III.
It's surprising that "in this day and age" people still look at videos and news stories as if they are actual representations of reality. Say it's real: since she knows there's a hidden camera over there, is it possible she decides, oh, I don't know, to play up the damsel in distress and not throw a chair at him or not blow pot smoke in his face or not reveal that what she illegally downloaded was lesbian porn? "Oh my God! That's no excuse for him beating her!" Of course I'm not excusing what he did, I'm not even talking about what he did, I talking about why America is obsessed with this.
Do me the respect of admitting to whoever is drinking a latte next to you that if these people were black, you'd have a whole different reaction. If you even had any reaction, because most probably this video would have sunk to the bottom of the Sea Of Youtube with only one comment that said, "what's amazing about this video is that the father is actually still living there."
You want to see superb belt technique go visit a Toys-R-Us in an inner city, and I have a weird feeling that the reason wannabe gangstas never wear belts is because of negative reinforcement.   Furthermore, after carefully reviewing the data coming from every black comic ever those kids are getting a beat down from their moms as well, proving my thesis that if you punch a white girl it becomes a Breaking News, punch a black kid and it's hilarious. And let me offer without further comment a phrase you will inevitably hear the first time you try and slap your black girlfriend: "don't you raise your hand to me, you fucking nigger, you ain't my daddy."
I'm making this point not because I want to be on the Jon Stewart show, but to point out that our reaction to the video isn't about right and wrong but about identification. And when the media elicits your identification, it is never about what you like but about what you hate.

Jim Hopper, a clinical instructor in psychology at Harvard Medical School and a child abuse expert, said there is no doubt that the judge's actions crossed the line.
"This is an act of brutal violence," Hopper said. "To beat someone into submission is not discipline. To beat a child into submission makes it harder for that child to take in rules and the values that the parent believes they are imposing on the child."

Jim Hopper's a pussy. Can I say that on the internet? Note that the sentences do not logically follow one another. Is it brutal because it fails as a discipline tool? Does it fail as a tool because it is brutal? He is not offering any insight into what happened, just repeating the feel-good non-sequitors that got America into this mess in the first place.
Properly understood, the beating has nothing to do with discipline at all, the discipline is an excuse for a discharge of rage that was already there and was coming out one kind of way or another. That's why when he leaves the room after beating her he is relaxed, relieved. "Finally, now I can sleep!" People have felt compelled to point out that "all she did was download music" as if they were looking for some level of crime that would fit the punishment but that's precisely the point, there isn't any, it's not about the crime but the excuse to hit something, which is why I would advise my clients who appear before him for sentencing to be as deferential and as respectful as possible, explicitly, verbally, recognize his authority, because he will most likely be a softie about any kind of crime that does not reflect badly on himself.   Got it? Beat your kid and he'll sentence you to life, rob a bank or plead psychiatry and you'll be back on the streets in 48 hours. But bump a pretty woman wearing just the right kind of white heels and just the right shade of red lipstick and you may as well swallow your fingernail clippings, justice will be done.

IV.

Someone, e.g. the daughter Hillary, is at some point going to note the irony that her father punished her for using the internet, and she was then able to use the internet to punish him back. But that's not how it's going to play out, not with narcissism.
Sure, initially he's going to feel very ashamed that everyone sees him this way. But prior to the premiere, he had to carry around the secret of her beatings, and if there was any chance he ever felt guilty or perhaps thought that at times he was excessive, what he will do now is find enough (>1) anonymous (= "objective, they don't even know me") people who say, "well, it's not that bad" and poof, guilt gone. Crowdsourcing the superego means never having to say you're sorry. Never mind 99% of the comments and articles want him registered on a database, those guys are idiots or liberals or the media or whatever, he'll align himself with the 1% and walk proudly down the sidewalk. "Not only do people know I didn't do anything wrong, now I know it as well. Thanks, Hillary. I feel a lot better."
Furthermore, there is the very real probability that public is going to go Rebecca Black on her, finding it first progressive to hate the father, but as soon as the "we have to fight child abuse" crowd joins in it will be way cooler to turn around and support him. If there is one thing Americans hate more than a father beating his daughter it's finding themselves in agreement with people they can't stand.
The other equally likely possibility is that the exposure, the narcissistic injury, is going to be too much for him and he will kill himself. America may cheer this outcome but I suspect Hillary will be at least ambivalent.

"I'm very relieved that these things have been brought to light and not because I want to see my father burn or anything like that. That's a hideous way of thinking and I don't want to inflict that upon him," [Hillary] said. "I cannot stress enough -- I cannot repeat myself enough, that he just needs help."

Sorry, not buying it. I understand and empathize, believe me I do, but there's only rage in those words, and I am predicting the future by telling you it is of no consequence to him and suicide for you. I'm going to be hated by everyone for saying this, but there is an important difference between what happened to you and how you use what happened to you, and one of those you have to live with and the other one everyone else has to live with. And you will never be free.
If all rage comes from narcissism and narcissism is the broadcasting of a chosen identity, what identity is she broadcasting? Victim.   Even if youtubing her abuse is somehow cathartic, it reinforces victim as an important part of her identity to herself, and this will infect every single relationship she has forever, from husband to kids to dog to God. Again, I am making a distinction between the abuse affecting her, and unconsciously defining herself by the abuse. After a few years of rehearsing you will no more be able to get rid of that trauma and expect to get on with life than you can pull the power source out of Megatron and expect he'll be able to turn into a jet. So I am telling her early, and I am telling you early, you who have nothing to do with these people but still feel not sympathetic but enraged, as much as you want him to suffer that desire is hurting you. I understand it, I respect it, I get it. But it will kill you. Forgiveness at any cost is the only way out.

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===== ====== ===== The Last Psychiatrist: Judges Accused Of Supporting Social Change As Per Script
Their main crime was that they got paid for it.

The story:

For years, the juvenile court system in Wilkes-Barre operated like a conveyor belt: Youngsters were brought before judges without a lawyer, given hearings that lasted only a minute or two, and then sent off to juvenile prison for months for minor offenses.

The explanation, prosecutors say, was corruption on the bench.

That's one possible explanation, the other is that this is the way courts run nowadays.

The short version is two judges are alleged to have received kickbacks from the private juvenile justice center for every kid they sent there; so they sent a lot of kids, for a lot of time. The center can bill $260/day.

Leave aside whether the judges are guilty or innocent. Observe, however, why it was that the scheme worked. It worked because of the criminal justice system has been offloaded to psychiatry.

I don't know this particular facility, but I do know what a "juvenile detention center" is: it's a place you go and wait until your court date, assuming you can't make bail. So these kids were waiting in this facility, for however long the judge cared to make them wait.

How can you do this? What about due process?

You simply say they're not competent to stand trial.

There may have been some "prison" like housing as well, i.e. post-trial sentencing to be in that facility, but all of the above apply: it could be justified because it wasn't just punitive, there was "treatment." (If there actually was.)

There was an older county juvenile jail, but it was shut down because it was "falling apart" but, more importantly, because it didn't provide modern "services." You can't lock kids up for months for nothing; you have to provide them with treatment for their illness-- obviously, that's why they committed a crime in the first place.

Note well that this scam was detected not because someone noticed large numbers of kids were disappearing into the black hole of the juvenile justice system, but because the owner of the prison was using company money to buy jets, boats, etc.

As I said before: the only red flag of impropriety for anyone, anymore, is money. As long as you don't get paid for it, you can pretty much go Zodiac, and no one will notice.

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===== ====== ===== The Last Psychiatrist: Just Because You See It, Doesn't Mean It's Gone

This is a post for psychiatrists/psychologists who do long term psychotherapy, sorry everybody else. Pandering to my base. It's an election year.

This is the email I got:

Dear Alone:

You wrote a while ago:

No one ever asks me, ever, "I think I'm a narcissist, and I'm worried I'm hurting my family." No one ever asks me, "I think I'm too controlling, I'm trying to subtly manipulate my girlfriend not to notice other people's qualities." No one ever, ever, ever asks me, "I am often consumed by irrational rage, I am unable to feel guilt, only shame, and when I am caught, found out, exposed, I try to break down those around me so they feel worse than I do, so they are too miserable to look down on me."

If that was what they asked, I would tell them them change is within grasp. But.

I might be asking myself something like that. If I tell you a story would you tell me what you think?

II.

Imagine a crowded subway, and a beautiful woman gets on. Hyper-beautiful, the kind of woman who can wear no makeup, a parka, earmuffs and a bulky scarf and that somehow makes her look even prettier. A handsome man about her age in an expensive suit gets up and says, "please, take my seat." She smiles, and hastily sits down.

What happened? Raise your hand if you think this is a sexually motivated act, i.e. Christian Grey isn't so delusional that he assumes she's going to have sex with him, but in a Hail Mary, longshot kind of way it's worth the price of standing for three stops.

Now raise your hand if you think he was just being nice-- he would have done it for any woman. Huh. Really? Then why was he sitting at all?

But why does the woman think she got the seat? Does she think, "the only reason he gave me his seat is because the Hail Mary is worth the price of standing for three stops?" Or does she think, "no, come on, he was just being nice."

We can't be certain why Hugo Boss gave up his seat. But if the woman picked b, we know something about her: she sees the world as intrinsically nice, it's a place where random kindness exists and hence must be a reflection on the physics of the world, not her specifically-- "New Yorkers are so nice!" she says, and she actually believes it.

In other words: the goodness is in him, not in her.

III.

One of the frustrating things for therapists is a patient who is unable to see reality. Maybe it's a guy who takes every little thing his ex does as a sign she wants him back; or it's a college kid who is failing his classes because he thinks it's more important to "help Jen with the crisis she is going through"; or maybe it's a woman who thinks men aren't interested in her.

In the course of therapy she explains she wishes she could meet a good guy, nice, with a good job, someone like the guy on the subway. And you're stumped, didn't she meet a guy on the subway who was exactly like the guy on the subway? "Oh, no, he wasn't interested in me, he was just being nice."

You can guess the backstory: father left when she was 8, mom was always telling her she was too fat and too skinny, an "overly critical maternal superego" which is different than a paternal superego because it yells at you not when you sin but when you fail. This is the mom who doesn't want you to have premarital sex, of course, but a girl like you should be dating the captain of the football team. So the men who do ask her out, the ones she ends up dating-- fearless, calf tattooed men who make their attraction to her explicit, even vulgar, so she can't help but know that they want her and what they want from her. Meanwhile, these guys then treat her like crap. So she lives her life thinking that the only people who like her-- the people she has to settle for-- are... not great.

Genetics took care of her body but the upbringing affected her vision: the childhood of never good enough filters her present reality, obscures it, she can't see what is plain to everyone else, e.g. she's beautiful. So the process is to uncover the reasons why her view of reality is distorted and help her realign with reality. Use insight to strengthen her damaged ego, or, if you want a ten step approach, block automatic thoughts. In short, to understand that she is good, that men do find her attractive, not just the brazen ones, not just jerks.

IV.

If you think of narcissism as grandiosity you miss the nuances, e.g. in her case the problem is narcissism without any grandiosity: she is so consumed with her identity (as not pretty) that she is not able to read, to empathize with, other people's feelings. She doesn't care to try because it conflicts with how she sees herself. Ergo: Giorgio Armani was just being nice.

I recognize, of course, the countertransference: that I am attracted to her, it is impossible not to be. Of course I'm also in full control of myself, I don't break the boundaries of treatment. But I also see that she doesn't see I'm attracted to her, in fact I often observe how little attention she pays to my "feelings." She treats me as if I am a voice only. Once I had a cast on my forearm and she made no mention of it. What does this suggest?

Two or three years later, nothing has changed except-- she drinks more. Huh. Things did not go according to plan.

What happened? What happened is my analysis of the countertransference was purposefully self-serving, "see, I'm a good therapist in detecting this" which defended me against the truth: yes I was able to admit to myself that I was attracted to her, but what I was unwilling to admit to myself-- that anyone outside of me would see immediately-- was that part/all of my eagerness to help her was that she was beautiful; and the way in which I know to impress beautiful women is by giving gifts, helping-- as it was with my own mother. Not that I was so delusional as to assume she'd have sex with me, but in a Hail Mary, longshot kind of way....

And since I was having those feelings, and those feelings are BAD, "inappropriate" as we say in therapy, then it is entirely likely that rather than not correctly seeing reality, she saw it and guarded against it: by deciding that men--me-- don't want to have sex with her, they are just being nice.

What I didn't consider is that her blindness to the desires of men is necessary to her sanity-- that she doesn't want to believe that every man's interaction with her is sexual; she doesn't want to have to live in a world that only sees her naked. She wants the world to be... nice. Take as the origins anything you want, maybe abuse, maybe she started noticing at 15 how all the neighborhood fathers looked at her a little differently than they looked at the other girls; too many date rape close calls, jealous girlfriends, whatever you want.

Which means that my push to get her to see reality is interpreted by her as yet another sexual advance-- because it is. When she walked in she was able to block out the possibility I was attracted to her, but through diligent application of reality testing I forced her to see my erection-- "look, I really want to help you understand what you do to me!"

Fortunately for her she doesn't exist, I made this story up, but it serves to illustrate an important point: rather than assume people are too damaged to interpret reality, the default assumption should be: all of this is a defense against change. (1)

V.

Here's a story I didn't make up, though I've altered it to simplify a complicated situation and protect his anonymity.

Joe had a girlfriend, and though they were happy the relationship seemed to run it's course, and she took up with another man. Despite this, she couldn't fully let go of Joe, so they still talked and texted and met once in a while.

During talks some things came up, notably things about Joe, notably Joe's apparent indifference in the relationship. For example: "I was also hurt," she said, "that when we broke up, it didn't seem to bother you."

Joe told me it did bother him, perhaps more in retrospect (now realizing how much he liked her), but he wondered if his lack of emotion wasn't a signal of a larger problem- an inability to connect.

So: multiple texts, chats, and, at one meeting:

We met and we cried very much, she said she was sad that we weren't together, but it still made sense for her to be with that other guy. We ended up kissing and crying at the same time. After that I didn't see her for about two weeks. But we continued to talk, she'd said that she missed me, and I missed her too. She said she'd been crying everyday since she that last meeting, wondering if....

Because of that I arranged to see her again, but this time she said she had made up her mind and decided to be with the guy. She also said very quickly that she fantasized about us getting back together someday, but not now. In this kind of situation I always try to be strong and say that the person is not responsible for me, but this time I collapsed and cried. I asked her if she still loved me, she said "Yes, but it can't be right now". (2)

Eventually they meet again, and on the way home... things get murky. He says he badly wanted to kiss her, but she did not want to.

"She stopped me. I said "Ok, then I'll leave", but then she asked me to stay. She said she was divided, and very anguished, she thought she was doing something wrong. I said it was not wrong, because she loved me and love can't be wrong (or some similar catchphrase). I tried to kiss her again, this time she didn't resist but she wasn't very passionate either. I noticed she was very sad. I said I loved her. She said "stop it", and ran off.

So I'm trying to think what I did wrong, and what I'm asking myself is:

- How could I not pay attention to her feelings, making her anguished just because I needed that kiss? I see that I was extremely selfish that day-- here she was crying and ambivalent, and all I felt was horny-- and throughout the whole process I could only think that I wanted her for my own needs and forgot about how she felt.

Even though I always asked her if she wanted me out of her life and she said no, why do I even need to ask? Why couldn't I just see that she was crying and tried to comfort her instead of trying to kiss her?

So:

How do I stop hurting people?

I know that I'm only thinking about that because I had a loss and I miss her a lot and I want to be a better person so I'll have a better life, but still it's good to become a better person and stop hurting people.

This time I really want to change who I am because who I am is not working.

I wrote a reply about their relationship, which highlighted her ambivalence and how such ambivalence in women is often resolved. However, he wasn't really asking for advice about the relationship, but rather advice about being a better person. Was he wrong for pressuring her when she was so conflicted? Did he ignore her feelings? How can he change?

He wrote back (excerpts):

1. I see her ambivalence and her conflict. Maybe I'd have an easier time if I just said "I want you, dump the guy"....

2. I feel jealous now that she accepted the "no more texts or dates or anything". Because at first the fact that she fell in love with someone else didn't stop her from expressing love towards me. Now it did. Now I'm jealous....

4. Yes, I feel guilty for the day when she was crying and all I could think of was trying to kiss her. I didn't use strength, didn't hold her or anything, she accepted my kiss but very sadly. Sometimes I think about it and it feels almost like I raped her. This fact specifically is what made me write to you: I wouldn't share that thought with anyone who's close to me. Is that shame or guilt? Or both? I know that she didn't see it that way because later that day we talked and she told me she didn't want me to leave her life and she couldn't forget me. Which is consistent with your interpretation.

4.a. I had noticed narcissistic behavior in me before several times and I've been trying to change. For instance, somehow I thought I'd look ridiculous giving someone a gift so I didn't usually did that, no matter the circumstance. I originally thought giving a gift was about me, a reflection on me, not about the person receiving the gift. When I came back from Denver I brought a Broncos jersey for my little brother, but I was worried about what my father would think of me and about my choice of a gift, and stuff like that, but I focused on how my brother would feel receiving the gift. It may sound silly but for me that was a big deal. It pisses me off that I forgot to pay attention to her feelings in this situation.

My reply:

I now understand that this kiss is what prompted your email, this specific incident. I recognize you feel guilty for pressuring her into a kiss. And she was crying, which should have stopped you (you believe) but it didn't. If you were blind to her feelings you could say, in retrospect, you are a selfish person without empathy who doesn't notice other people's feelings, who only does what he wants. But it wasn't blindness (you tell me), you knew full well she didn't want to kiss you, yet you proceeded anyway. This makes you even more of a narcissistic monster. Is this a correct hearing of your story as you intended it to tell me?

The problem is that you are telling me two stories.

On the one hand, you are telling me a story about your "guilt" over taking advantage of her vulnerability and kissing her when she didn't want it. Which is odd, because apparently kissing her wasn't really an example of taking advantage of her-- she didn't think so, right? She told you so herself later. So then it was a kind of dialogue: her ambivalence wanted a firm response, and you (against your ordinary nature) were surprised to find yourself compelled to give it to her.

You kissed her; you say-- your words-- that she didn't see it as any kind of "rape"-- but did she feel any guilt for kissing you? For cheating on her boyfriend? I'm not saying she should or should not, merely that one would expect her to be wrestling with her guilt. But instead on the phone later she is discussing yours, making you feel like you did nothing wrong. If you follow me so far, then talking to you and easing your guilt isn't primarily because she cares about your suffering, but because it allows her to avoid looking at her own. If you "forced" the kiss-- and by saying you didn't force it she is saying it's okay that you did--- in forgiving you she would be benevolently implying the fault was yours and she was blameless. This isn't malicious or intentional, this is all unconscious, it is performance: can I trick my superego? Since I was crying, how much could I really have wanted it?

But none of that is important, because there's a second story.

Your next paragraph to me describes narcissism-- my "specialty"-- and worrying about how a gift would be seen by your father, and (ultimately) doing the right thing and focusing not on your feelings but on your brother's. But how can I not read that paragraph and think:

father=TLP
brother=ex
gift=kiss

and

"I thought giving a gift was about me, not about the person receiving the gift" which is, "what will you, TLP, think about this, now that I am thinking about other people's feelings? Will you be critical like my father, or will I get your approval?"

I know you'll counter that you in fact did give a gift to your brother, but the juxtaposition of the example you chose from 10 million other possibles cannot be a coincidence. Which is why it is important to focus on the words.

So what is the right interpretation of that paragraph, 4a? Why does it follow so logically from 4? Why are you telling it to me? Like all these things, it's a defense against change: "see? I think about other people's feelings." But that's the narcissism. The narcissism isn't forcing a kiss on her; the narcissism is the thinking that all of these events with your ex are entirely yours to decide, to bear the responsibility of. She is merely a supporting cast member that wasn't nearly as sophisticated, insightful, intuitive as you. You want to bear the guilt because it shows you-- and me-- you are a better person.

Please understand that this is not a judgment of you, it is (my opinion) of how you see yourself.

Your first story is the age old story of unresolved feelings for each other, oozing out between the clenched fingers of a tightening fist that thinks it can will emotions into control. But the insight for you is that your "narcissism" isn't a lack of empathy but the opposite: other people are all little brothers, ex-girlfriends, supporting cast, who are less able to make good decisions, so the world needs you to do it.

I would say that ethically you are still supposed to act as if you had unilateral responsibility; but simultaneously you have to be able to see the other as a fully autonomous, free, aware person.

In summary: you could feel (a little) guilty for kissing her when you knew it was wrong; but the real problem for you is that you naturally reduced her to a person with less agency than yourself.

VI.

The problem with therapy-- include self help and mind hacks-- is its amazing failure rate. People do it for years and come out of it and feel like they understand themselves better but they do not change. If it failed to produce both insights and change it would make sense, but it is almost always one without the other.

In Joe's case, it is supremely tempting for both patient and therapist to focus on the problem he is describing-- "I feel guilt over pressuring the girl, does this make me a narcissist?" And the therapist can generate a series of insights which the patient accepts, which although correct lead nowhere.

What's missing is an analysis of the transference. Joe added an entire paragraph 4a which was-- superfluous? It served only to stroke my ego, i.e. "you've helped me, here is an example where I was able to apply your lessons." It's that paragraph in its seeming uselessness that reveals his real motivation in writing me and hence his actual problem. He's offering ME a story about how he forced himself on a girl- and was legitimately bothered by doing it-- but telling it to me is basically saying, as in 4a, "here's an example where I did something bad but I also feel guilt about it-- if I feel guilt, I must be changing-- see, I learned the lessons!" He specifically references the difference between guilt and shame because he knows I know that narcissists never feel guilt, only shame. So rather than that guilt being evidence of self-awareness, that guilt is a trick for my approval. He sounds like he's asking for advice, "how can I change?" but what he wants is in the transference: "Dad, did I do good?" It is that seeking of approval that is the heart of his problem, not his relationship with women, not his "narcissism" of kissing her when she didn't want to.

A really good therapist will be able to get to this kind of depth; someone who will not take the chief complaint at face value, but will focus on the words.

And yet: still this will fail to produce any meaningful change. Insights plenty, but no change. Is it because I am wrong? No, it's because I am not Alone.

VII.

It's a cliche in psychiatry to "analyze the transference" but never mind no one bothers to do this much anymore; it is completely impossible to do this.

I may have been quite clever in telling him the interpretation of the transference in 4a, but the problem is that when I told him "you are seeing me as a kind of father" I was saying it AS his father. Not: I stopped being me and became his father; but from the very moment I responded to him, every single word I wrote was coming from his father. You can't step outside the transference, there is no objective place for me to stand and tell him my thoughts, and there's no safe distance for him to stand and hear them. So if I say, for example, that I do or don't think he handled his ex correctly, I am saying that as his father-- i.e. critical, judgmental, kind, forgiving, whatever.

If I think that by explaining the transference to Joe I somehow dispel it, as if it were an illusion that once explained could never fool him again-- then I won't understand that while I offer further insights or interpretations, while my lips are moving, all he is hearing is: angry at me; love too easily obtained therefore of no value; thinks I'm a fool; thinks I'm a genius.

Then what Joe will do to me, his therapist, is exactly what he does to his own father: try and fool me into giving my approval. And if he doesn't get it one way he'll trick me another. His email can be understood as just this kind of a trick; the focus on the guilt over the kiss is a way of saying got me, "see? I'm changing! Validate me!"

Here is another danger: if I (TLP) think that when I explain things to him, that he and I step outside of the transference and speak objectively-- as if we are talking about Joe while he is sitting in the other room-- if I think this objective stance is not only possible but desirable-- then what I am teaching him to do is to self-observation, I am training him to examine his own actions and thoughts as if he were a neutral person inside his own mind. But that other person would be me. Grant me 50% of the time I'm awesome. What about the rest? Would that person have helped the beautiful woman on the train, or driven her to alcoholism?

Given that the problem here is a kind of narcissism (a description and not a judgement) then by fostering self-observation I am actually worsening his narcissism. And he will inevitably say, "I know myself better, but I'm still doing the same things."

VIII.

So it becomes important not to fall into that trap, to foster change and not just insight. If I was actually his therapist then the correct thing to do would be NOT to tell him all this, but rather to note it to myself as information: "this is the nature of the transference." It's hopefully of some use in an email because since we don't have any kind of relationship; since I am not likely to meet him, it's better that he understands how this works than. But in therapy there is no value in it to the patient.

In fact, as his therapist, my urge to explain it to him would be my own unKantian narcissism: using him as a means to show off. Telling him my great insight is the same as my desire to help a beautiful patient: it is for me, not for them. In therapy we see a reversal of my often repeated maxim: if you're saying it, it's for you.

And so what? What's wrong with giving advice? Because (in his case) he doesn't want advice, he wants validation. And if he doesn't get it from me, he'll do what he already told me he would do: "...I was worried about what my father would think of me... but I focused on how my brother would feel receiving the gift." In other words, he'll find someone who does. This is his real problem: the constant search for approval from Dad, women, wherever. And of course it will never be enough, because that's the nature of the pathology: if he gets validation he'll be temporarily appeased, but eventually devalue it because if it was obtainable by him, it must be valueless.

I can infer from this that he sees his father as generally right but overly critical, and Joe says to himself, "I'm a good person, everyone else thinks I'm a good person, but no matter what I do I can't convince my father of this." This is self-doubt, and it quickly becomes: "I've fooled everyone else, but my usual tactics don't fool my father" and so Joe is trapped between hating his Dad for being so mean but still/therefore suspects he's the best judge of character out there, which means Joe suffers not from high self-esteem, but low self-esteem. This is why my approval (if I were his therapist) is so important to him and simultaneously so damaging: "TLP is equivalent to my father. I may not be able to get my father's approval, but if I can get TLP's then it confirms that I am good." And change is thus unnecessary. The point there is that he doesn't want to change, he wants a reason not to change, he wants to be seen as good without having to earn (whatever it is he believes is necessary to get) his father's approval.

IX.

Therapists should understand the imaginary transference but not play into it, and instead stay outside, an abstraction, an inexplicable mind that already knows all the answers but doesn't tell them (because telling them is inside the transference.) Whose silence is taken by the patient to mean something-- and the answer to the patient's problem is how they interpreted that silence.

This is why I know that though Joe will "like" my email to him very much, think it helpful, it is this post that he won't like that will actually help him more. He can't say anything to me here, there's no dialogue, the post just is: all he has is what I've written here and his feelings about it; and it is those feelings, not my post, that hold the answer for him.

The moment the therapist speaks, he stops being a symbol of knowledge and becomes a person to be fooled (or loved or devalued or punished or whatever the nature of that particular transference is.) A post, a story, and the (mostly) silent therapist are the opposite: a screen to project on so that patient or reader can then ask, why does this make me feel like that? (Or, more rigorously: "what do you want from me?")

This is why readers probably find the my posts about other readers' problems so powerful. When you read a post about my interaction with someone else, you are assuming the role of that outside neutral observer that is impossible inside the dialogue. Not completely, of course, there is always some fantasy about who I am and who Joe is, what we are like, but clearly you are more outside our transferential situation than we are.

For these reasons, I am becoming convinced that the only real way to "personal growth" outside of direct action is through careful study of fiction. Of course stories may have an intended meaning, but a well written story allows you to ask not just "what does the story mean?" but "why do I think that this is what the story means?" As in The Second Story Of Echo And Narcissus: "The story is the pool... what do you see in it? It's a reflection and a projection..." (3)

---

1. If you want to observe the extent to which you are not in control of your countertransferential feelings (women included), get a swimsuit model as a patient-- and let someone else watch you do the therapy. Do you dare? I once had the magical opportunity to watch as a resident was told in rounds that the patient being transferred to him by the graduating resident was "gorgeous, a model". Someone threw a switch, he changed immediately: more professional; softer, more articulated speaking; more mature-- all before he ever saw her. It was as if some part of him said, "yes, it makes sense I would be chosen." But even more impressive was how the rest of the residents treated him over the course of the year. There was some envy but his patient elevated him in their eyes, as if he was a better person, a better therapist. (Similarly: all on-call psychiatrists have had the secret feeling that a doctor's chaotic patient is a reflection on the doctor.) They asked his opinion on matters when it was neither necessary nor even... a good idea. His proximity to a beautiful woman who came to see him made him more of a man-- and of course he wasn't dating her, it was random chance he was picked-- but it gave him a kind of merit as if he had had something to do with it, which was in retrospect silently justified, "he must be good if she stayed with him." This was true of the female residents as well, and, most importantly, the attendings. (I wonder how they would have interpreted it if she stopped coming.) The simple fact that he was appropriate in the sessions was enough to indicate his talent. It should be no surprise that with this amount of unexplored countertransference from him (and all of his colleagues) that no progress was made in her therapy.

2. Though this post isn't about the woman, please observe that she is running a kind of story here, the theme of which is, "I desire the feeling of desire." She likes emotional energy. She breaks up so that there is a deep sadness (Act III) so that there's back and forth resulting in the climax of reconciliation. "We're in love!" Importantly, in order for her to get what she needs from this narrative, they don't actually have to get together in Act IV, it is only necessary that she sees her life as a story with these four acts-- so the breakup is only possible (or easy) because she anticipates that at some point in the future there is an Act IV. NB: no mention of Act V. She isn't aware there is one, which is her life's problem, which is why this story will repeat with her other relationships, including the one she's cheating on now.

3. It would be an interesting experiment to read a story and write down your feelings and interpretations of it, and then return to the story a decade later.

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===== ====== ===== The Last Psychiatrist: Just How Many Drinks A Day Is Bad?
Is a glass or two of wine a day good for you? You would think this would be an easy question to answer, but it's not, and that's because of this:
How many glasses of wine are in a bottle?
If you answered 4-5, continue reading. Because guess what? Apparently the answer is eight. No, I'm not kidding. Yes, they are serious. Unplug your monitor and ram it into your skull as hard as you can.

"Doctors don't know. They pretend to know. Because they have a rectal thermometer in their pocket. As if it were an appeal to a higher authority."-- Lewis Black
It comes down to this: medicine doesn't have all the answers, but in presenting their recommendations it sounds like they do. And we get confused.
"Two drinks a day." What's a drink? Are the health benefits/risks of whisky and wine identical? Then why lump them together? And if the answer is, "well, we don't know enough yet" then why are you making recommendations with the authority of medical certainty?

The reason wine's benefits/risks seem confusing is that no one emphasizes the size of a "drink."
A "drink" is often defined as 10g alcohol-- that's 1/8 of a bottle of wine.
Many reference guides, in an attempt to make things simple to understand (if you're drunk, maybe) use 10g/drink as a standard. There are 750ml in a bottle of wine. If the bottle is 13% alcohol by volume, then there is 98ml alcohol per bottle. Alcohol's specific gravity is .79, so there are 77g alcohol in a bottle. That means that there are 7-8 "drinks" in a bottle of wine, which, if I may editorialize, is so preposterous as to hardly merit comment.
Similarly, for 5% beer, there is 0.05 x355ml x 0.79= so 14g per 12 oz can. Is a beer a drink and a half?
Alcohol content varies greatly among wines and beers:
Also, each wine has a different alcohol content-- 12.5% is the typical French ideal, and most wines are built (i.e. alcohol osmotically removed) to stay under 14% because the tariff increases above that.   There is a leeway of 1.5% in the listing, so 12.5% could be 11% or 14%. That's a 2 "drink"/bottle difference.
In the past few years, and especially with California wines, Syrahs, Zinfandels, places with hot climates, the trend has been towards using higher Brix (sugar content) grapes. (Riper means more sugar, which means more alcohol.) About 55% of the sugar ferments to alcohol, and the common 25 Brix grapes convert to a 13.75% wine. Plus you lose some water in the wine making process, so it may be even higher than that (15%).

To complicate things further, each policy group advocates different safe drinking levels that are nearly incomprehensible to the layman, unless you convert them to some common measure (here, I convert to grams): The U.S. government says no more than 2 drinks per day-- but that's 14g each. France says no more than 5 per day-- but it's 12g each. Britain says 3-4 "units"-- at 8g each! Do the British know this? A British study (in Scots) found that people generally pour out two, not one, unit per drink. It's no wonder people are confused.
A better conversion is this: there is 77g alcohol in a 13% bottle of wine. That's equivalent to almost a six pack. Go.
Blood Alcohol Content: as accurate as a New York Times poll, but you can still go to jail.
Converting to grams as a reference for drinking is useful because it allows you to predict your BAC. Here is how everyone tells you to calculate it: If you drink 40g alcohol and weigh 70kg, your BAC will be .05% (40g/70000g). Or, if you weigh 70kg, every 14g beer will raise your BAC by .02% Or, every 1/4 bottle of wine raises the level .035%. Isn't math fun? I have seen countless "reference tables" using this method.
But the units of BAC are g alcohol/100ml water. You're not all warer, are you? You're about... 60% water? So that 40g alcohol in really in 70kg x .6= 42kg water. 40g alcohol/42000ml water= .09%. Congrats. You're drunk. Sort of.
In practice, those reference tables telling you your estimated BAC already incorporate the Widmark constant-- the percentage body water. It can range from 40-85% water. The more water you have, the lower will be your BAC. Women have less water, so their conversion runs lower (40-50%). Muscle= more water; fat=less water. The problem, obviously, is while BAC calculations use a standard-- for example, my .6, above-- individuals can vary greatly. Hence, lawyers.
But wait: Breathalyzers. It's measuring the alcohol content of your breath, not blood. What's the ratio of alcohol in breath to blood? 2400:1? 2100:1? Generally, breathayzers are calibrated to underread your alcohol level, by about 10%. So even though most humans run 2400:1, it is calibrated at 2100:1. But don't try to argue "individual variability" of a breathalyzer in court: 2100:1 is part of the statute, and thus your reading is your sentence.   But remember, liquid to gas transitions are described by Henry's coefficient: heating a substance (e.g. alcohol) puts more in the air (breath); cooling the air (breath) makes the substance stay in liquid (blood). So before you blow into the machine, hyperventilate and roll in the snow.
The point here is that you-- and guidelines-- cannot predict your BAC based on how many "drinks" you had, because there are so many confounding variables.
Note that BAC doesn't tell you how drunk you are-- tolerance might mean you're an effective Lisp programmer at .1%, or you're beer goggling at .02%. At a given weight, higher percentage body fat= more drunk. Also, food delays absorption. Finally, some people metabolize alcohol faster than others; the old rule "a drink an hour" is based on the assumption that you metabolize 10g alcohol per hour (or your BAC falls by .01%/hr)-- but in you it may be 20g/hr (e.g. a daily drinker), or 5g/hr (e.g. young woman rarely drinks, on Tylenol) etc.

But legal driving limit is usually .08%. And 50% of the time, .4% is death, so there's that.
Health Benefits of Wine? Or No?
So since the term "drink" is uselessly vague, in reviewing the literature on wine and beer's effects, I'll do my best to convert to grams of alcohol. Just remember that a bottle of wine is 77g, and 12oz 5% beer is 14g.
Cholesterol, triglycerides, coronary artery disease: about half a bottle of wine, but at least 20g/d, raises HDL,;decreases TG, CRP, fibrinogen, and decreases risk of CAD.
Generally, moderate alcohol consumption (say, 30-40g/d) is associated with decreases in mortality. This is hypothesized to be related to a) its HDL raising effect; b) its reduction of pro-inflammatory proteins CRP and fibrinogen (i.e. it's anti-inflammatory.)
One of the studies, in Nature, that popularized "moderate consumption" was this: 40g/d (from beer) for men, 30g/d for women, reduced inflammatory markers C-reactive peptide (35%) and fibrinogen (12%), increased HDL (10%), with no change in TG or liver enzymes. after 3 weeks of drinking.   The study called this "four glasses" but a better way of understanding it is three beer cans or half a bottle of wine. Also: BAC 1 hour after drinks was 10mmol/l. Yes, mmol. Sigh. 46g/mol: BAL .046%
A prospective study confirmed the "well-known" relationship between alcohol consumption and HDL, which rose from 40 to 50 with >30g/d alcohol.
A German study of 7000+ people found HDL rose, and fibrinogen decreased, for women who drank 10-20g/d and men >30g/d.
A Danish study found an interesting relationship: women who drank at least once per week had lower risk of CAD than abstainers; but drinking more often did not promote the effect. But for men, daily drinking (more than less frequent drinking) was associated with the lowest risk.

Oxidative Stress: doesn't ethanol cause lipid peroxidation (free radicals?) Answer: you're not drinking ethanol, you're drinking wine--which probably increases antioxidant capacity.
This is how you get plaques: free radicals in your diet (e.g. cooked fat) promote LDL oxidation, which goes on to promote arterial plaque formation. Free radical scavengers, such as Vitamin E, would lessen this effect-- but are consequently reduced. Importantly, the LDL from a meal is more susceptible to oxidation than normally circulating (fasting) LDL.
Alcohol promotes oxidation in test tubes. So why wouldn't it do so in people? For example, a careful study controlled for many confounding variables that are associated with high or low alcohol intake-- such as smoking, vitamins, exercise, etc-- and found that the more alcohol consumed, the higher the oxidized LDL, with no change in HDL. Where did the protective effect go? One possibility jumps to mind: median consumption was 6g/d; and the above studies found the relationship with the higher "doses." And you need to be a regular drinker: 96 hours after a single dose of wine there was no effect on LDL. Surely I've made this up? No: 300ml red wine (better than 300ml white wine) inhibited oxidation (e.g. LDL oxidation). The likely explanation is that even though alcohol can cause oxidative stress, wine-- and it's constituents (polyphenols, resveratrol, etc) may overwhelm this effect. But you have to drink enough (>300ml) so that it overwhelms alcohol's effects (but not so much your wife leaves you.)
Additionally, wine's beneficial effects in preventing oxidative stress may be enhanced when you have more oxidative stress to begin with. Take the easy case of eating a fatty meal. The LDLs that result from this meal are more likely to be oxidized than the normal fasting LDLs in circulation. Drinking 400ml of wine with a meal made these post-meal LDLs more resistant to oxidation than even the existing LDL, and maintained the Vitamin E levels. And in case you're a rat, in rats who were force fed a high cholesterol diet, wine reduced the cholesterol levels and improved antioxidant parameters.
Not just meal related oxidative stress: 1/3 bottle of red wine a day for two months in people who just had angioplasty substantially increased antioxidant reactivity and decreased oxidative damage. There is a logic to this: the lower your CRP, the better is your natural antioxidant capacity, and wine lowers CRP proportionally more if it is already high. A glass of wine (or one espresso- how do you like that!) was equivalent to an orange or 200g spinach in antioxidant capacity.

Homocysteine (which causes coronary plaques)?   Maybe it goes up a little, but that might not matter, especially if you're drinking wine.
42 men got to drink half a bottle of WHITE wine a day for a month: lower oxidation products (and coincident increase in free radical scavengers and HDL), but also increased homocysteine.
A prospective study found that after 6 weeks of 30g/day of wine/beer/spirits, homocysteine levels were higher than in controls. Folate levels were also lower (except in beer-- because beer has about 30ug folate/beer and0.1ug vitamin B6/beer.) Folate and B12 are cofactors in the conversion (methylation) of homocysteine which is then broken down (sulphyrated) with vitamin B6 as a cofactor; so low folate/B12= high homocysteine. Similarly, in chronic alcoholics homocysteine was much higher-- but less so with beer.
And again, but with 40g/d drinking wine and spirits for three weeks, homocysteine went up 9%. Beer had no effect. But B6 went up with all drinks (more with beer). Not only does B6 facilitate homocysteine degradation, it is also an independent inverse risk factor for cardiovascular disease.
But perhaps amounts are relevant: in another prospective study, 1/2 bottle/d of red wine for two weeks had no effect on homocysteine, while doing the expected increase of HDL and antioxidant capacity.
A study using pig coronary arteries found that while homcysteine impaired endothelial cell relaxation, red wine negated this adverse effect.
It appears that homocysteine goes up, but that doesn't translate to any increased cardiovascular risk because of some beneficial effects of the wine, which may include B6, antioxidants, increased HDL and increased antioxidant capacity.
Blood Pressure? Answer: No serious effect below a bottle of wine a day.
German study (above) finds <80g/d associated with <2 mmHg increase; >80g/d associated with 4-6mm Hg increases. American Idol makes mine go up more.

Much of the negative data on blood pressure is perplexingly inaccurate. By "perpelxingly" I mean that the errors could not have simply been oversights, could they? People are lumped together, as are quantities and types of alcohol, giving misleading results. For example, in an article entitled, "Alcohol is Bad For Blood Pressure"-- seriously, that's the title of the scientific article-- the authors state:
Since then, large-scale prospective studies from Japan (6) and the US(7) have indicated that the risk of hypertension increases twofold with alcohol intake of 30–50 g/day or more.
Hmm. "Increases twofold." I'm not sure what article they read, but reference 7 pretty clearly says the opposite:
Our principal finding was the association between the consumption of low to moderate amounts of ethanol (up to 3 drinks per day) and either the incidence of hypertension or increase in blood pressure levels in blacks. In white men, there was no evidence of an increase in systolic or diastolic blood pressure over time at this level of consumption. Similarly, for most beverages, a low to moderate intake of alcohol was not associated with a higher incidence of hypertension in white men and with an increased incidence in black men.
And later:
the observation that low amounts of alcohol intake may not increase blood pressure in most race-gender strata could lead to a more tolerant view of the consumption of alcohol in small amounts...
Black men who drank heavily had double the incidence of hypertension (defined as a jump to > 140/90): 15% vs. to 30% in drinkers. But I should add that the risk was relevant only in black men who drank beer or spirits; only 8 out of 250+ drank any wine at all.
Thus, blood pressure is minimally affected by wine, and even beer or spirits, if other variables are controlled. There is a negative effect of beer and spirits in blacks that needs to be explored, as does the effect of wine in blacks.

Pancreatitic disease: How many drinks before you're in trouble? Answer: >30% of your daily calories from alcohol if you poor nutrition; or >1 bottle wine/day for 25 years, especially if you eat like a pig.   Smoking=death. (But you knew that.)
You'd be amazed at how hard this simple question was to answer.
As an aside, almost every study done in 2005-2007 on alcohol and pancreatic disease was done in Japan or China. I'm sure there's a reason for this, but for the life of me I can't tell you what it is. And if someone is able to explain to me how the Japanese and Chinese physiologies are generalizable to everyone, I'd like to hear it; but that's what happens.
The main problem with the studies is that risks of pancreatitis are associated with an arbitrary cut off that does not reflect the actual toxicity of alcohol. For example, a study found that >2 drinks/d, compared to <2 drinks/d, was significantly associated with pancreatic necrosis. So we're all going to die? The problem is that this association was either/or, not calibrated to amount. For example, what if those who had the necrosis all drank more than 10drinks/d? It would still be true that the risk was higher at >2 drinks/d. So why 2/d as the cutoff? "The cutoff of two drinks per day was selected based on animal studies which have shown that the equivalent consumption of two drinks per day in rats results in measurable change in pancreatic histology and physiology(13)." So, of course, I looked up (13): in rats who received 12%, and worse with 36% of their calories from alcohol increased pancreatic protein hypersecretion, starting the road to pancreatitis. If you eat 2000 calories a day, then this would be equivalent to a little more than 1 bottle of wine/d.
A Japanese study found that the traditional rates of pancreatitis among alcoholics-- 2-5%-- may be low: they find that 9-17% of people who drank >150g alcohol/d developed alcoholic pancreatitis. The alcoholic pancreatitis patients began drinking at a younger age (18), drank for 20 years) and drank 180g/d alcohol. Additionally, they cite other studies where meat and lipid may be co-factors.
An interesting study found the risk of acute pancreatitis may be increased in the first day of withdrawal of drinking; these drinkers had drank an average of 700g/week (400-900g), and 3600/two months. Alcohol suppresses inflammation, so this may be a rebound inflammatory response.
A Chinese study found that smoking, high meat and heavy drinking was associated with pancreatic cancer. Heavy drinking was ">20 cup-years;" basically, 11g/d for 20 years, or 22 g/d for 10 years, etc. The article did not address the hihger rates od ALDH2*2 allele of aldehyde dehydrogenase in the Chinese, which slows the metabolism of aldehyde (and allows it to build up-- see below.)
Another Japanese study (come on) found risk increased 10 fold for >100g/d, and >30 years of drinking.
Alcohol alone is not a risk factor for pancreatic ductal adenocarcimona, which is most closely associated with smoking. Alcohol may indice pancreatitis and diabetes, which are themselves risk factors. Also, acetaldehyde, an intermediary metabolite of alcohol which is ordinarily quickly metabolized to acetic acid, is procarcinogenic; heavy drinkers with cancer, vs. alcoholics without cancer, had higher salivary aldehyde levels due to fast metabolism of alcohol to aldehyde. (I SPECULATE that binge drinking, and frequent exposure to acetaldehyde (read: hangovers) is more dangerous than low but daily drinking.)
Finally, you should know that many studies describing the risks of alcohol are not able to control well for smoking, which is a major risk factor. Consider that 60% of chronic pancreatitis cases are smokers; but 80% of alcoholic chronic pancreatitis cases are smokers. And high BMI is a risk.
Diet and alcohol: in animal models of alcohol induced pancreatic disease, & calories due to alcohol is the measure. For example, one mouse model uses 24%, and the mice had BAL 100mM (.46%). Most animal modesl use about 30%. One study disputed the high protein/high fat risk of pancreatitis by finding that humans with pancreatic or liver disease took 50% of their calories as alcohol, and the worst cases had the highest percentage intake. A study in Mexico found high overall caloric intake (4110 vs. 2250 in healthy controls) was the risk factor, but dividing the average daily alcohol (124g=868 cal) by calories (4110) gives you 21% calories from alcohol.
The type of alcohol here is not described. Was it red wine? Vodka? Beer? You decide.

So there are two prongs: high caloric intake, especially from fats and protein, and consequent high BMI, along with alcohol (>100g/d, conservatively;) or poor nutritional intake with higher proportion of alcohol calories (>30%). With both, smoking is a profound risk factor, especially for cancer.
Stop smoking.

Resveratrol:
Resveratrol (a type of estrogen (DES)) is a polyphenol contained in wine (and fruits, grapes, etc.,) that is itself anti-inflammatory and antithrombogenic (it's a COX1-- COX2?-- inhibitor), as well as possibly being neuroprotective. It probably is an anti-flu drug. It can possibly prolong life span through SIRT1 (which is how calorie restriction prolongs life.)    Resveratrol is one possible explanation for why the French can eat fried butter sandwiches with a bottle of wine and still tell their grandkids about it.
There is no accepted dose. A bottle of red contains about 1mg, unless you're drinking muscadine wine (Florida grapes, some ports, etc.) It appears to have no toxicities.
I bring it up here only to tell you that as much as I think resveratrol is super and all, it oxidizes very quickly after the bottle is opened. So drink fast.
Calories:
There are 7 calories/gram alcohol. So each bottle of wine has about 550 calories. Each light beer is 110 calories. There are about 50 calories in a shot of whisky.
Summary And Conclusions:
Disclaimer: I'm not recommending anything to anyone, I'm not your doctor, results may vary, substantial penalty for early withdrawal (HA!). Don't drink if you have GI disease. Or if you drive. Or if you're on medications. Or if you're an idiot. Especially if you're an idiot.
But it appears to me that 30-40g (1/3- 1/2 bottle) of wine alcohol a day is fine. Enjoy it. (Unfortunately, I'm a whisky guy.) It seems to work best if you drink it with food. Everyone else should just mellow the hell out. This unprioritized rigidity, this obsession, with "health" and "prevention" is idiotic and counterproductive. Today I cooked my family bacon and eggs. BACON. Take that, AMA's beliefs.
Some caveats: most of the association studies, above, do their best to control for confounding factors, but sometimes this is impossible. As a basic generalization, the person who drinks 1/2 bottle wine with dinner is likely to have a very different life than one who drinks 4 beers/day after work, notwithstanding the obvious confounding variable of alcohol with/without food. So it may be impossible to say that wine, itself, is what is beneficial.
Despite this-- and why this is relevant to a psychiatry blog-- the error is to assume that one is "the type of person who drinks wine, and so would have lower risks" vs. "the type of person who drinks beers, and so would have higher risks."   It may be more accurate to consider that if one chooses to become the person who drinks wine with dinner instead of beer after work, a variety of other factors may also change. As a simple example: beer at a bar is conducive to smoking, wine at home isn't. Beer after work every day may be sabotaging your family life; a choice to switch to wine at dinner may improve things at home. &c., &c.
This is important. It is the thesis of this blog: nothing matters more than your will. Even if wine and beer are themselves of no consequence to one's health, the lifestyle that follows with the conscious choice to drink either one is of consequence. Every choice you make influences your identity, and not the other way around; the sooner you accept this, the sooner you can become the person you want to be. You get to pick who you are. Go pick.

(State laws prevent me from receiving donations of wine (or whisky.) My drink is Balvenie 15 year. It's about $65. Just saying.)
See also: Is This The Real Secret of Wine's Health Benefits?

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===== ====== ===== The Last Psychiatrist: Kanye West And The Video Music Awards

I.

This is what he said:

I'm going to let you finish... but Beyonce had one of the best videos of all time! Best videos of all time!
Hey stupid, this is the award for Best Female Video, not Best Video Of The Year. Best Video is at the end of the show.

But you knew that, didn't you?

II.

Question 1:   Why would Kanye West jump up to support Beyonce? Why not Britney Spears? Slow down, racial profilers: would he have done that for any/every black artist? Why Beyonce?

Question 2a: If one of the Jonas Brothers had taken the mic away from Beyonce and said "3OH!3 has the best video!"--- what would have happened?

Question 2b: Who would have beaten them up? Do you think it would have been Kanye West?

III.

The VMAs aren't scripted, they are structured. Structured shows are particularly deceiving because the audience is focused/distracted by the reality/improvisation/story, oblivious to the underlying control.

The structure of the VMAs isn't the same as the Oscars, i.e. an award show culminating in the award for Best Video Of The Year. If it was the same, then why did my DVR say there was still another 20 minutes left in the show?

IV.

The Muppet Show was about a cast of muppet performers putting on a variety show at the Muppet Theater-- the show you were watching. It had three perspectives.

The backstage "unscripted" antics: Kermit trying to produce or direct; Fozzie practicing a joke on him, or setting up a bit; the drama with the guest star, etc.
The onstage scripted "performance"-- The Muppet Show that took place in front of the curtain. This included skits (e.g. Swedish Chef), Fozzie's standup, and, most importantly, "the Big Number"-- the live guest star's performance at the end.
Looking at these two elements alone, the TV show's structure was: the first five minutes were backstage about starting the performance; then onstage the performance had its opening number; then a backstage issue; then an onstage skit, then another backstage issue, etc. Even though TV viewers saw a 30 minute show, the onstage "The Muppet (Variety) Show" performance filled only half that time. The onstage variety show's highlight was "The Big Number." But the TV show's story was about the drama of getting to the "Big Number."

This is an old set up. But unlike many other "shows about the show," The Muppet Show had one additional element:

The audience actively commented on the show, in the form of the two old men, Statler and Waldorf, in the box seats. "Look how stupid this performance is!"

It's not for nothing that the VMA artists are constantly reminding us that these awards are special because we, the fans, nominated them.

If a show is scripted and an actor goes off script, you're sunk. But as long as the structure of the show is protected, it doesn't matter at all what happens within the show, the outcome will always be the same. People could get naked, curse, fight-- it changes nothing. In fact, at some point, these unplanned outbursts become anticipated.

All that determines a successful show is: can Kermit get us to the Big Number, or not?

V.

Another analogy: it matters to you how a football team plays, who gets injured, misses a catch. But to the people that directly benefit-- the NFL-- the money will flow no matter who wins, as long as the structure of the game is intact. If Michael Vick meanwhile wants to drown some puppies, that's his lookout.

The business of the NFL is not football. The business of the NFL is business.

VI.

One scripted VMA subplot was Russell Brand's monologue, which was unsurprisingly horrible. Brand is a hilarious standup comic, but it's impossible to perform something scripted when the audience is expecting something supposedly unscripted. That's why every presenter's stupid attempts at humor were stupid-- they were scripted for an unscripted show, and it showed. The best jokes will still inevitably fail under these conditions.

Another scripted subplot involved Eminem and Tracy Morgan trying to get Best New Artist. This evolved over multiple segments (waking up, training on a treadmill, singing with Cyndi Lauper) until they eventually gave up ("we'll get 'em next year, homey") and presented the award for Best New Artist. It was funnier (though not much) than Brand could be because these were prerecorded segments; they took you out of "live performance mode" and you valued it as a scripted skit, e.g. no expectation of spontaneity.

The visceral disgust most people felt at Kanye West was evidence that it was not a staged stunt. If it was, you would have smirked an "oh please."   This doesn't mean West didn't plan to do it, it means Taylor Swift didn't expect to have it done.

VII.

The audience-- people, Twitter, performers, Leno, The View, the President-- are can't help but comment on the show. They don't understand that they are actually part of the show. They aren't getting paid, but neither were Statler and Waldorf.   And they were the funniest part of it.

My DVR may have said there was another 20 minutes of show left, but it was wrong: there's still another week or so.

VIII.

The VMAs, like The Muppet Show, are about getting to the Big Number. In that sense, The 2009 VMAs are really the Jay-Z New Record Release Party.

This subplot-- scripted but presented as spontaneous-- was that Jay-Z was not in the house, but he was coming.

Before commercial breaks, shots with subtitles like "Jay-Z's motorcade on the way to the VMAs" were shown; Jay-Z was coming!

On one of these breaks, the voice over was: "How will Jay-Z appear for his grand finale?" Yes, how? What will he have to say about all this?

I am almost 100% certain that not only did Kanye West plan to do this, but that Jay-Z was in on it. Rappers regularly have other people do their "dirty work"-- it makes them appear to have power. But that's my opinion, and it is absolutely worthless: how would I know?

But what I do know is that when you want to make a show called the Jay-Z New Record Release Party, here's what you'll need: an already established crazy person to say what you're thinking, allowing you to distance yourself from the suicide bombing; you'll want a sexy, gracious, generous, magnanimous wife who rises above the controversy and gives her speech time to Taylor (oh, look, Taylor happens to be right backstage ready to appear);

you'll want as much hype as possible pre-game; and the grandest of grand entrances.

This is how it ends/begins. Walking from backstage to onstage, seen from his perspective.

They don't show anyone leaving.

IX.

"Why do we keep talking about this crap! Kanye West?! Who cares!"

Do you think I'm unemployed, have tons of free time? Do you think I listen to Jay-Z records? I haven't seen the VMAs for a decade. Yet here I am. Something made me write a post on Jay-Z this week... somehow I watched-- looked forward to-- the VMAs this this year. Oh, weird coincidence: this was the most watched VMA in history. We were all compelled before it was broadcast to want to watch it.

"Not me." You're missing the point. Maybe the VMAs didn't get you, but something is getting you, and those somethings are all the same thing.

Pop culture controls you even if you think you're separate from it. It is everywhere, from the clothes you wear to the language you use to the way you think. It is a viral pandemic that masks infection by pretending to be part of you. There's no cure. But if you know the structure of the virus, at least you can recognize the infection as not-you.

"No way, I'm not getting infected, I'm not exposing myself to all that trash. I'm going to think for myself."

That's the virus talking.

---

http://twitter.com/thelastpsych

---

more on Jay-Z

===== ====== ===== The Last Psychiatrist: Kerouac's On The Road: The 50th Anniversary Of A Book I Had Not Read

So I read it.
What is striking is how little it resembles the book everyone seems to think it is.
Has anyone actually read this book? Nine people total, all literary critics?
Enough has been written about the book itself. A more interesting question is why so many people got it so wrong.

I can't be the only one whose impression of the book, from hearing about it but not actually reading it, was that it was about young, potent men, lost in a growing commercial society, two coiled springs ready to pop, looking for adventure-- America style. And this Road Trip that launched a thousand, other boring, useless road trips, was about young men looking to experience the world, really see, really live, really feel, free of the constraints of an artificial post war soulless society. So, khakis on and Moleskine's in shirt pockets, top down on an old convertible, they set out to find life. Testosterone, benzedrine, and a full tank of gas.
Well, guess what? That impression is wrong. You know what the book is really about? It's a primer on how to be a narcissist.
Right off the bat: these are not cool guys. This isn't even Henry Miller uncool. This is not a dismissive insult, but the only word that can be used to describe the Sal Paradise/Kerouac character is "dork." Remember the guy in high school who quoted Monty Python and the Monster Manual-- seemed smart-- but was unable to distinguish himself in any meaningful way? He has big ideas, of course, but is full of ambivalence, lacking in any type of purposeful drive, no real direction. Restless, but lazy. That's Sal, that's On The Road. This is not testosterone augmented with benzedrine. This is a guy who likes his naps. Here are the first two sentences of the book:
I first met Dean not long after my wife and I split up. I had just gotten over a serious illness I won't bother to talk about, except that it had something to do with the miserably weary split-up and my feeling that everything was dead. (1)
You can already tell this is going to be the story of a passive guy who needs to be lead.
Well, he finds such a leader in Dean Moriarty. I won't bore you with the character analysis; suffice it to say that Dean is (I guess) the "free-spirit" character everyone imagines the book must be about, bedding women, stealing cars, doing whatever the moment calls for. I know it sounds very superman, literary, but it's not. Dean isn't an antihero, or even amoral, or a free spirit-- he's simply a jerk. I defy anyone to identify anything he does in the book that is worthy of any sort of praise or emulation. When he talks, your sole instinct is to open fire at a Starbucks. You don't want to be Dean Moriarty, you want to bitch slap him. Not only does he do nothing of any value to anyone, he does nothing with purpose. He's a bullshitter without any reason to bullshit. It's empty, idiotic. Here, I literally opened the book to a page and put a finger down:
[Sal] said, "there must be some ideal bars in town."
"The ideal bar doesn't exist in America. An ideal bar is something that's gone beyond our ken. In 1910 a bar was a place where men went to meet after work, and all there was was a long counter, brass rails, spittoons... Now all you get is chromium, drunken women..."
Here's another, again at random, I swear:
"The truth of the matter is we don't understand out women; we blame on them and it's all our fault," I said.
"But it isn't as simple as that," warned Dean. "Peace will come suddenly, we won't understand when it does-- see, man?"
I've heard these same kind of sentiments expressed hundreds of times, not ironically always in bars and coffeeshops. And I had the same reaction then: if she sleeps with him, I'm going Unabomber.
But enough about the characters, what about the spirit of the book? You know, getting out there, seeing life?
The notion that they're trying to experience things or learn things or grow is precisely wrong. That's the mistake nearly everyone I talk to has made. The experiences are incidental, the learning completely absent; the real purpose of the trip is to say that you went on the trip.
It seems impossible to me that you could take a trip around the country and literally notice nothing about your surroundings, but that's exactly what happens. I know "America" is supposed to figure prominently into the spirit of the book, but it could easily have been A Railpass Through Europe or Backpacking Through The Warsaw Pact and it would have made no difference, at all. That America is not well described could be dismissed as poor writing, but it's actually an example of very accurate writing: the setting has no external importance whatsoever-- except as it impacts them. That's narcissism. It's simply a prop for an image they want to convey; traveling down Route 6 for them is the same as the career of the female lead in every romantic comedy (writer/designer) or the apartment of the male lead, rich or poor (Soho loft.)
They're always rushing to get to the next great place; every place they get to turns out to be a disappointment. And so off again to the next great place. For some reason this is taken to be the result of some inner passion, some drive to experience new things. It's not. The real point of the drive is: as long as they're traveling, they don't have to confront the reality of a place.
The entire spirit of the book can be summarized by Dean's words: "Sal, think of it, we'll dig Denver together...!" That's what a man who is trying to con a woman into running off with him would say. Denver, really?? Really? Why? Because it starts with D? I'd at least momentarily entertain the theory that D cities are great places to get to, but the real reason he wants to get to Denver, or anywhere else, is precisely because the longer he stays in any one place, the better chance he'll be discovered to be a loser. Time to go where the grass is greener, somewhere people don't know you're there to crap on it.
That's what the Road is. The Road isn't freedom, or possibility, or growth; it's denial. It's not having to confront the triviality and purposelessness of your existence. It's not having to listen to your Mom tell you you aren't going to get into college with those grades, or a wife who nags you about being out all night drinking instead of fixing the bathroom because, well, you've been out all night drinking and not fixing the bathroom.
This narcissistic ambivalence is the root cause of their disappointment in each-- the same reason dating is so hard for some teens and 20-somethings. You don't actually want a girl, they want the possibilities of a girl, before she becomes a real person. Before you learn she likes American Idol, before you discover her annoying laugh, and, most of all, before she finds out who you really are-- before you can't fool her anymore.
If you want further evidence of this parallel, consider the book describes numerous encounters with really young girls. I'm guessing Kerouac wasn't trying to convince us he was a pedophile; So why tell us? Take it at face value, what appeal could there be? The same as for any regressed pedophile: it's easier to convince a young girl (or a broken girl) that you're somebody. The strong but introspective loner; the mustached, Porsche driving, sophisticate; a good lover, a genius, an artist, whatever. Try that on a normal woman and you know what you get? Fake orgasms.

This is the story of two guys at the junior prom, standing in the corner, fantasizing about what it'll be like after they get discovered. Not that they're taking any concrete steps towards that end beyond simply fantasizing.
And further supporting their small mindedness-- they're thinking about what those girls at this dance will think about them ten years from now.
Narcisissm is consciously creating an artificial identity that you then fight tooth and nail to get others to believe is true. That's On The Road. Not just the plot of On The Road, but On The Road itself. Consider how it was written: everyone knows that Kerouac was high on benzedrine, and the book poured out of him, in three weeks of sleepless creation, typed onto a single, long scroll of paper, unedited, raw, real. But here's the thing: the book wasn't the result of that process, he planned that specific process in advance, on purpose.   Same with the cross country trips-- this wasn't a restless guy, who had to travel, had to move, and then later wrote a memoir; he went on the trips in order to write a book. He actually started the book before he even went on the trip. The process didn't generate a book; the process was the whole point. The novel's popularity rests entirely on the image around it, that he created, on purpose. That's why its popularity exists despite apparently so few people actually having read it. If the book had been published anonymously, no one today would have ever heard of it.

This is the main problem with people who love On The Road but have never actually read it. They think Kerouac is in that book, so they think they like Kerouac. Or, at least, the person they think Kerouac is, i.e. the character in the book, or, more accurately, the character they think is in the book.
This partially explains some of the problem Kerouac had after the publication of the book. By the time it was published in 1957 he was 35, but it was about trips he had taken ten years earlier. People hounded him see if he was like Dean (in fact, Kerouac was Sal, but everyone wanted him to be the "cool" character.) They wanted him to be a young, free-man hipster type, not a lonely alcoholic living with his mom. But that's what he had wanted them to think when he wrote it. When he's taking the trips and writing the book, creating an identity and convincing people of it is all that's important. But by the time he's 40 and that fake identity never really pans out, he's disgusted with himself. I'm going to guess that of the 9 people in America who have actually read the book, most read it in high school. If they read it as adults, they'd probably feel about it like Kerouac did at 40:
At the end of the book (SPOILER!) Sal/Kerouac becomes disillusioned, disgusted with Dean. Relationships end for everybody, but what's different is Kerouac is disillusioned by Dean as a mentor. Who the hell has mentors? Answer: people looking to become something they are not. That's what happened to Kerouac. Now he's 40: he's not Sal, he's not Dean, he's not a hipster, and damned if everyone didn't misunderstand the book (of course: they had only read about it.)   I can understand why he becomes a drunk. That's where unrequited narcissism always leads.
It seems a lot of people have developed notions and ideas that are partially informed by On The Road-- the version that they imagine exists, the one with Nietzschean super-antiheros looking for truth behind the wheel of a convertible. But what happens to those ideas when you one day discover that your version was wrong?
Here's your tie in to medicine. Doctors like to remind people that "there's still a lot we don't know." That's a distraction from the more truthful version, "there's a lot we don't know about what is already known, that we're supposed to know." They have notions of what the clinical trials showed, or what Freud said, or how medicines work, that are wrong-- but they're basing entire careers on these wrong ideas.
Here's the thing: even when someone actually sits and reads the primary text and finds it is different, it doesn't replace their existing (wrong) information, it only supplements it. There's not one On the Road that people got wrong; there are now two On The Roads, one they read and one they imagined existed, and they get to pick which one they want. I guess that's ok, as long as it's only On The Road.

------
1. Interestingly, Kerouac's original version wrote not of the separation of his wife, but of the death of his father, which is not only more accurate, but considerably more powerful, especially as it related to "the feeling everything was dead." I don't know what to make of this change.

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===== ====== ===== The Last Psychiatrist: LA Fitness Shooter George Sodini Did Not Kill Because He Was A Misogynist

all of this has happened before and it will happen again

click here for analysis of his blog

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===== ====== ===== The Last Psychiatrist: Language And Behavior, Embodiement, and Chronic Pain

apparently, effective

Fast food makes you... faster?

57 college brats watched images flash for 12ms on a screen. That is too fast to consciously perceive. One group saw colored squares, the other saw fast food logos.

Then they read a passage. The control group read it in 84 seconds, the fast food group read it in 69.

Repeat: 12ms is too fast to consciously appreciate.

II. The embodiement of lying

87 college kids were asked to either tell the truth, or lie, in one of two formats: a voice mail message or an email. They actually performed the message.

Then they were asked to rate the desirability of some products, including mouthwash and hand sanitizer.

When they lied with their mouth, they preferred mouthwash. When they lied with their fingers, they preferred hand sanitizer. When they told the truth with their fingers, they didn't want hand sanitizer. They were already clean.

III. Tylenol reduces psychic pain

62 college kids took 500mg Tylenol BID, or placebo, for 3 weeks. Every day they completed the "Hurt Feelings Scale" (e,g, "today being teased hurt my feelings.")

Tylenol users felt less psychological pain. However you want to explain this,

it is evident that being on Tylenol made the brain work differently.

IV. Locking up negative thoughts

80 college students were asked to write about a recent decision they regretted. Half were asked to seal their answer in an envelope and turn it in, the others just turned it in.

Those that sealed their answers reported feeling less upset, less negative than those that didn't. The obvious but easily overlooked point is that the subjects didn't seal their answers in order to gain closure; the increased closure was the "accidental" consequence of a physical behavior. This physical action produces a psychological analogue because Freud was right: the unconscious operates like a rebus. The act is read by the unconscious in its own way, abstractly, semantically.

V.

The point of all of this is not to suggest that we are desparately out of touch with our bodies, purposely disconnected, unwilling to accept that its flaws and strengths are intimately tied to our personalities and behavior, though this isn't such a bad thing to suggest. The mind/body problem hasn't been solved not because it is philosophically or scientifically insoluble, but because it is a psychological defense. You may be able to circumvent Darwin but you can't beat Freud.

Consider someone with somatoform disorder, who has physically manifested some psychological pain. You can't logic this away, you can't show them normal MRIs and blood tests as evidence that it's psychological, because they're not operating on a logic level, they're not even operating on a verbal level. The ability to manifest the pain physically instead of psychologically means this is a more basic, unconscious maneuver.   So it's not that they don't believe the MRI is normal, they are fully convinced of it; but they're not making a distinction between mind and body the way you are.

An analogy would be your computer crashes. So? You may be able to identify some of the internal parts and you know what Windows "is" but you have no idea how they work together, what affects what. So you say, "my computer won't start" and the IT guy is frustrated, "you mean there's no power, or there's power but Windows doesn't load, or...?"

The fact that your brain made your lower back hurt is not qualitatively different than the fact that a tiger made your back hurt. The fact that Prozac makes your back feel better doesn't mean it wasn't "really" your back.

Some of you will recoil from this thinking, and you're the same people who ask if there's no power or Windows itself won't boot up.    I sympathize, but you can't talk his way out of this.

Behavior got you into this mess, and behavior will get you out. The more words you use to explain/encourage/dissect/intimate the more the behaviors or symptoms dig in. Words are perceived as a trick, like a kid suspicious of mom talking up broccoli. The pain is there for a reason, and you're trying to fool away the pain without taking away the reason.

VI.

The solution to managing this kind of mysterious chronic pain is to not manage the pain, but the behaviors. The problem of physically manifested psychic pain is the problem of learned helplessness, which means the longer you suffer like this, the more likely you are to give up trying not to suffer like this.

Like a POW, you can't tough your way through the pain, it will outlast you. You can't trade short term benefit for long term set back because again, it will outlast you.

This kind of pain I am talking about-- crippling, debilitating, and infuriating to everyone else is more about the consequences of the pain than the pain itself. You may actually have been injured by a tiger, but what has paralyzed you now is your brain wondering:

what's going to happen to me?
This will never get better.
My husband will leave me because of this.
I will never be able to work because of this.

and a bunch of what ifs/if only:

if only I hadn't fed that tiger
if only I had iced it sooner
if only I could do it all over again I'd--
what if this is a sign of something worse?

That's the part of the pain that is crippling. Anyone can tolerate any kind of pain as long as they know there's an end in sight or that it doesn't prevent you from being yourself.

So you have to find a way to make your body do the things that are you:

"I will never work again"---> what kind of job could I do?
"it hurts much worse today"--> acknowledge the days when it hurts less
"my husband will leave me"---> maybe this is a good opportunity to try a menage

and stop planning things which are impossible, in the future, or delay tactics

"I wish I hadn't fought that tiger"
"I'll rest it for 6 weeks, then..."
"I'll order aquatherapy, then..."

All that matters is what you are going to do today. Do something.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Law Says To Science, "You're Kidding Me, Right? "

The $253M Vioxx verdict against Merck is overturned.

(It was actually only a reduced $26M verdict, but since the media didn't highlight that fact when Merck lost, I'm following in kind.)

Meanwhile, A New Jersey court removed a $9M punitive damages award in another case, and upheld another Merck verdict in another case.

The court found no evidence that Vioxx caused a fatal cardiac embolus, because-- surprise-- there isn't any evidence. At best we have an association, not causation, and it may be that the Vioxx itself has nothing at all to do with death. (Though I realize that the law accepts association as evidence.)

The score is now Merck 11, plaintiff's attorneys 3.

Question: well, what are they supposed to do when there's some evidence that a drug poses a health risk? Ignore it?

Answer: who is they? There isn't supposed to be a they at all. (There it is again, the steady creep of social democracy, sister of narcissism.) There's a chemical, it exists, doctors are supposed to know when to use it appropriately. Not to mention it may later be discovered to have additional value (aspirin, thorazine, thalidomide, etc.)

When you create a body to decide for doctors whether a drug is worth the risk, then you are saying you do not trust doctors to make this assessment. Therefore, you do not need doctors at all, you need flowcharts.

Unfortunately, I'll admit, they might be right.

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===== ====== ===== The Last Psychiatrist: Lawsuit Funding

Sponsored post: as many bloggers are, I was offered $30 to review someone else's site/product. Ordinarily I pass, but this one caught my eye for reasons which will become clear.

Anylawsuits.com offers non-recourse cash advances for pending lawsuits.

Here's how it works. Joe sues his doctor for, say, damages of $100,000. Trials last anywhere from one to 30 years. When might Joe get paid?
This firm will call your lawyer, determine how much you'll probably get, and give you that money today, up front, no strings attached. If you lose, you never pay it back. If you win, you pay them back plus "fees," which I am guessing means a percentage of the award.
The reason this works is because most of the time the case is settled. For example, this firm may give Joe $8000 up front, because they're lawyers, they've talked to your lawyer, and they know it will settle for about 10%.
So such a service is great for people who are hurting for cash (for example, you get injured and lose your job); or who may need the money simply to keep the suit going.
But-- and here is the problem, at least for defendants (i.e. me)- it seems a very low risk way to get some money.
Take med mal. There are plenty of times that a patient is injured, and plenty of times when the injury is the result of a doctor's negligence. However, in the vast majority of cases (that's right, I said vast majority) no suit is ever filed. The patient doesn't bother. It's not worth the headache, the time, the meetings with lawyers-- for what? The possibility of eventually settling for $5000 after 6 years?
But now, it's that much easier for someone to file a suit, including a nuisance (frivolous) suit. In essence, why not? You get your money immediately. Hell, once you get your money, you don't even have to be motivated to do a "good job" of "appearing" damaged, because you already have your money that you never have to pay back. And as long as the numbers are small (<$10,000) my experience is that hospitals usually settle.

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===== ====== ===== The Last Psychiatrist: Life's Possibilities As Seen By Men And Women

time to change your perspective to include getting more glasses

Life's Possibilities As Seen By Men And Women

the problem isn't that one is right and the other is wrong; the problem is that they are different
===== ====== ===== The Last Psychiatrist: Liver and Medications

Here's how to think about the effect of the liver on drugs:
When you eat a drug, some of it gets bound to protein (albumin) and some circulates freely. Your body uses free, non-protein bound drug.

Most drugs are mostly protein bound-- notable exceptions are lithium, Ritalin, Lexapro (40%) and Effexor (40%). Low albumin-- as could occur in cirrhosis, severe malnutrition, etc-- increase the availability of the free form of the drugs. So low albumin + valium = more valium for you.

Next is volume of distribution (Vd)-- drugs with high Vd will diffuse into fluid spaces. So patients with a lot of edema will end up with lower useful drug (because it diffused into third spaces.) Be aware that diuresis may consequently increase the dose as it returns to circulation.

First pass metabolism is also important. First pass metabolism means that a substantial portion of the drug is metabolized quickly-- or, conversely, won't be metabolized if your liver is damaged. The appropriate doses of medications are based on functioning livers. For example, tricyclics are metabolized by 50% on first pass; which means, in the absence of a liver, you are actually giving twice as much drug as what you think you are prescribing. Zyprexa has 40% first pass. Dilantin, by contrast, has low first pass metabolism, so the dose is about the same.

There are two phases of liver metabolism.
Phase 1 occurs in smooth endoplasmic reticulum: reduction, oxidation, and hydrolysis. All the cytochrome P450 happens in Phase 1.
Phase 2 occurs in periportal region of portal triad: glucoronidation, acetylation, sulfation.

The trick of this is to understand that liver damage (cirrhosis, etc) affects Phase 1, not Phase 2.

This is why Ativan (lorazepam), Serax (oxazepam) and Restoril (temazepam)-- all metabolized primarily by Phase 2-- are favored in drinkers or cirrhotics. Also, renally metabolized or cleared drugs will not be as much affected (for example, Neurontin.)
I hope this was helpful. Please drink responsibly.

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===== ====== ===== The Last Psychiatrist: Lost TV Series: Desmond's Fear and Trembling

I'm no Lost expert, and I doubt the writers were thinking along these lines. But yesterday's episode got me thinking about how we become who we are.

For non Lost fans: Desmond believes he can sometimes see the future; he can see that Charlie will die. He also believes he is responsible to push a button; if he does not, the world ends.

He meets an Oracle, who also sees the future-- e.g. she knows the man in the red shoes (Wicked Witch?) will die-- but explains that it is futile to try and save him, because "the universe has a way of course correcting," that is, destiny will find another way to take his life. Save him from the scaffolds, tomorrow he gets hit by a bus.

So Desmond now knows Charlie is going to die. He's prevented the death twice, but he's feeling the futility of it all-- destiny is coming, hungry, and it will be satisfied.

Desmond has to choose whether or not to continue trying to delay the inevitable. Desmond is the Cowardly Lion. He's afraid, he's confused.

So be it. But the important question is not whether Desmond will continue to try to delay Charlie's death, or just give up. The real question is why Desmond actually believes such a choice exists. How does he think he knows the future?   Anyone else in his shoes would have come to a very different, more logical, conclusion: this is insane. What, he can predict the future? Worse: what, he's the only reason Charlie is alive? He's so-- necessary? Isn't that narcissism?

You might say, "well, in the logic of the show, Desmond knows he can predict the future, and so he tries to save Charlie." Wrong, and this is exactly the point. Remember how he correctly predicted the outcome of the soccer match-- but was wrong about which soccer match he predicted? Sure, ok, Charlie's going to die. When? 2014?

Was Charlie really going to die in the water? Was he really going to get hit by lightning? Is Desmond actually saving him, or is it all-- wishful thinking?

So what makes Desmond's story so powerful is not simply that he chooses to save Charlie again and again; what's more important is that he chooses to believe in a life that where he must make such a choice.

If Desmond knew he could predict the future-- if it was a fact that he could predict the future-- then saving Charlie would have little moral heroism. Any fool a step up from absolute evil would have tried to prevent a horrible outcome if he knew for certain what was going to happen.

What made Desmond worthy of admiration was, exactly, that he did not know for sure he could predict the future. He took it on faith that he could, and then proceeded to live his entire life based on this single, faith based, assumption. He put his money where his mouth was.

Desmond took a leap towards faith, not a leap of faith. He didn't have faith to leap with. He went towards it, picked it. He didn't know the button needed pushing, and so, like a soldier, took responsibility to push it. He took on faith that the button needed pushing and then furthermore decided it was his responsibility to push it, defying logic and sanity and evidence and, well, everyone else. The action wasn't just heroic; it was heroic and defining.

He decided that he was going to give his life meaning, importance, even if it was the most insane, solitary, depressing meaning available; and at the great risk that he could be wrong, a life wasted.
If you know for certain God exists, there is nothing noble in believing in him. It's only when you take the great gamble to live your life, your entire life, as if He exists-- at the risk of being wrong, at the expense of an easier, happier life-- that you define yourself as something greater.   And once Desmond so defined himself, arbitrarily, he was able to take the next steps necessary to grow, evolve.

And he does grow. Almost immediately, he becomes a better man: after accepting the logic in a worldview in which he can predict destiny's path, he then also accepts a responsibility-- saving Charlie-- that he also knows is futile. He knows he has to fail, eventually, but he's going to keep doing it anyway, because he thinks he can transcend his own logic.

And because of this, he will succeed.

That's the Key in the Failsafe.   How can you say that the button absolutely must be pressed, if there is a simple way of bypassing it? If pushing the button is the only way to save the world, why is there even a failsafe in case you stop pressing it? It's a tricky answer: it's because while the button was being pressed, the Failsafe did not exist. The Failsafe represents Desmond not failing, even in the face of reality. It isn't a pre-existing backup. Desmond's existence created the failsafe. Metaphorically, the Failsafe didn't exist until Desmond took the final step: after accepting the futility of his actions, but deciding to do them anyway, he then decided he would not fail.

No matter what happens-- no matter how certain the reality-- he knows he can not fail, and so he will always will a solution.

It's the religious existentialist position. Kierkegaard didn't think logic and reason was going to get us to any absolute truth, and it certainly wasn't going to help us understand an Unintelligible God (which is the same thing.) You just have to go to faith, embrace it, create a life using it as a postulate, and move forward.

It's narcissism done the right way. And, I suspect, it's the secret to a meaningful life: picking an existence that is of value to more than just yourself, even if that existence defies the logic of reality-- your biology, your environment, and, of course, everyone else. And once you have chosen who you want to be, once you have defined the parameters of this life, you force it to be true, as real as any gene or social factor. And know that once you have invested your life in this identity, this existence-- all or nothing, even in the face of the doubt and terror that accompanies your "rational" self--- it will be impossible to fail.

...as ye have always obeyed, not as in my presence only, but now much more in my absence, work out your own salvation with fear and trembling.

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===== ====== ===== The Last Psychiatrist: Louis CK on being a dad-- the hidden piece of his happiness

It's no secret I love Louis CK. He's funny but insightful in a way only comics can be.

And certainly sacrificing yourself, subsuming your own "dreams" and focusing on the dreams of your children is a thesis entirely consistent with this blog.

So I write this with that love declared upfront.

Here's the missing piece of his PSA about being a father.

A while after his leg fell asleep on the toilet, and before he had that epiphany to flush down his own personal dreams and devote himself to his kids...he had a divorce and moved out.

I have no doubt he is a great father. But-- and this is a big but-- it is much easier to go all in with parenting when the courts obligate you to give the kids to someone else every night. Don't yell at me, divorced parents, I'm not criticizing you, I realize you have other burdens. But if he hadn't had the divorce, I doubt he would have made this PSA.

So this isn't a judgment on him at all. Maybe he's able to focus so well on his kids because there's no reason to try and steal moments away. He knows he will have a blocks of time that are free of the greatest killer of creative work: interruptions.

And maybe modern married creative couples need to create a system or regular "breaks," I have no idea. What I do know is that it is much easier to be two kinds of people at different times, then be two kinds of people at the same time.

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===== ====== ===== The Last Psychiatrist: Love Means Not Letting The Other Person Be Himself

The anvil is the better choice: D6 to XO4

You get married in your twenties, but 20 years and three great kids later, not to mention the idyllic farm in Big Sky country, you seem to have made it. The rest is coasting.

From the NYT:

Sure, you have your marital issues, but on the whole you feel so self-satisfied about how things have worked out that you would never, in your wildest nightmares, think you would hear these words from your husband one fine summer day: "I don't love you anymore. I'm not sure I ever did. I'm moving out. The kids will understand."
Wouldn't be the first middle aged man who suddenly realized he belonged not with his family but in a pre-furnished uptown apartment living on take-out. They say that the older kids get over it, but that sounds like something a psychiatrist would say, i.e. completely made up.

Her parry:

His words came at me like a speeding fist, like a sucker punch, yet somehow in that moment I was able to duck. And once I recovered and composed myself, I managed to say, "I don't buy it." Because I didn't.
She figured that this was a mid-life crisis; not another woman, or a failing on her part, but the discovery that his "personal trajectory is no longer arcing reliably upward as it once did." So, she treated it like "a child's temper tantrum": she ignored it. For four months.

Not ignored him: she included him in all family activities, talked to him, set a place for him.   But she refused to engage in discussions about separation.

So he turned mean. "I don't like what you've become."

Gut-wrenching pause. How could he say such a thing? That's when I really wanted to fight. To rage. To cry. But I didn't.

Instead, a shroud of calm enveloped me, and I repeated those words: "I don't buy it."
He was... surprised. He tried different ways to get through to her, but she kept "not buying it."

"Go trekking in Nepal. Build a yurt in the back meadow. Turn the garage studio into a man-cave. Get that drum set you've always wanted. Anything but hurting the children and me with a reckless move like the one you're talking about... What can we do to give you the distance you need, without hurting the family?"

II.

My first reaction was: this woman is insane. e.g.:

(To her husband) It's not age-appropriate to expect children to be concerned with their parents' happiness. Not unless you want to create co-dependents who'll spend their lives in bad relationships and therapy. There are times in every relationship when the parties involved need a break. What can we do to give you the distance you need, without hurting the family?

I don't know what that means, but I'm pretty sure I don't like it.

And this clear example of needing to go on/off pills:

You see, I'd recently committed to a non-negotiable understanding with myself. I'd committed to "The End of Suffering." I'd finally managed to exile the voices in my head that told me my personal happiness was only as good as my outward success, rooted in things that were often outside my control.
What put me off was her unwillingness to see him on his terms. Identity may be arbitrary and malleable, but the one with the body has a bigger claim to it, right?    She wanted him a certain way, he didn't want to be that way, and she didn't care. She wanted to be the one who chose his identity.

Also, she was a writer which made me suspect the whole thing. Why does this stuff always happen to writers and not longshoremen?

III.

But as I mulled it over for two months, I had to defer, this woman had it right. She didn't overthink it.   The obvious thing to do would be to take it personally ("he's not in love with me because I'm old and fat"); the easy thing to do would be to use it to air out old angers with him ("you always took your mother's side!"); and the tempting thing to do would be to do therapy on him ("don't you think you feel this way because you're old and fat?")

But instead she let it evolve naturally. She got out of the way and let him do exactly what it was he wanted to do, which was, specifically, choose his own identity. What she hoped, of course, was that he'd choose the one he already had for the past twenty years. But it was a gamble, because he could have chosen to become a middle aged man who prowls airport bars looking for stewardesses. (I'll preempt your joke: when I did it I was a very young.)

The analogy is to adolescence, where the more you badger them about their ____, the more they're going to believe they really want ____; because they aren't identifying with ____, they are identifying with not-you. That's what teens do, that's what anyone who feels their identity is being decided by others.

He, representative of too many men, wanted not to be something new, he just didn't want to be anything decided by someone else, even if he actually likes that thing. I came to understand this when I reread his quote, with the additional last sentence:

...you would never, in your wildest nightmares, think you would hear these words from your husband one fine summer day: "I don't love you anymore. I'm not sure I ever did. I'm moving out. The kids will understand. They'll want me to be happy.

Why would this nut think that they would want him to be happy? On some level they might, but why would they choose his happiness over theirs, or their mom's? "They'll want me to be happy" are the words of someone who has no idea what he wants, and so picks the meaningless word "happy."

IV.

I had to concede that she does know him better than he knows himself, after twenty years; not because she has seen into his soul but because she hasn't: she's seen what he's done, repeatedly, for twenty years. That's who he is, regardless of who he says he is.

Not great example, but: he says "I love japanese culture, I love japanese food" but she knows to find him at the burger joint and not the sushi place. Who he is is "a guy who just says he likes sushi, but does like burgers."

Also, hopefully, she has a sense of what are his values-- again, not what he says they are, but what he does. So she might find it legitimately out of character that he wants to move out since, for example, he could tolerate her infidelity just to stay near his kids.

So if we grant her a particularly unique perspective on her husband, then she may be in a position to know what's a phase and what's not.

And hence what she did- potentially humiliating and even futile-- was the right gambit.

V.

Here's the depressing part: if she had let him go, via arguing or clinging or whatever-- then he probably would not ever regret his decision to leave. Living at the Residence Inn, he would sincerely think he had made the right choice, that he had to move on.

But he wouldn't be any happier. Different life, sure, but not better. This is what Laura intuited. He may as well have moved from Cleveland to Indianapolis and swapped Lacoste for Polo. "Wow, this is so much better." Meanwhile, he's left behind a perfectly good life.

Everyone will tell me their situation is different and it may be, so I'll say it like this: if outside, impartial people who know you both perceive it to be a mid-life crisis and not a fundamental problem in the relationship, then bank on it. The problem isn't the relationship, the problem is you.

VI.

One thing I almost forgot: Laura's husband is a dying breed.

The trend now-- generation <40-- is for the woman to have the mid-life crisis. Before you jump on men, it's a combination of factors.

On the male side, the drive for novelty and nueva vida loca is turned inwards, so that rather than chase new experiences they close off from the outside world and dream them. They don't end relationships, they stay caulked to the inside of one, unmoving, ungrowing, apathetic; while their minds and DVRs are an imaginarium. The few things they do choose to jump recklesslsy into are obvious go-nowheres: one night stands (for the married man); making a movie; daytrading. They're easy to attempt, and easy to blame on externalities when they inevitably fail.

They don't break up with the girl, they ignore her until she breaks up with them.

On the female side: well, reverse 50 years of history and it's what men went through. Promised the world as described by Coca Cola and whatever TV show was popular at the time. All opportunities are open to anyone who wants to work, a new car, a big house, a career. But no one told the men that those things were for their families, not for them, that none of this would make them happy, and, indeed, would make them realize how little their lives are really worth-- unless they understood that their lives had value only if it was of value to someone else. So for a while they chased sex, affairs, or took up an out of the house hobby (e.g.golf). Something to give them the temporary illusion that they were free, and that the world had possibilties, not pot roast and pot bellies.

That's where women are, encouraged like the men had been by media images that say, "of course you can! (if you have the right bag)." You can't.  It didn't make men happy, and it sure won't make you happy. If you think it looks stupid when a 40 year old man buys a convertible or has to go find himself or chases a 20 year old intern, think how stupid it looks when the woman does it.

Women since 1980 have been sold a big fat lie, the same one the men were sold since 1945. It didn't turn out well for them. It did make men drink more, so you can look forward to that.

-----

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===== ====== ===== The Last Psychiatrist: Love The Way You Lie (With Me)

wrong video

On Eminem's official Facebook page, he invites you to check out the world premiere of his album... on MySpace.   That's the first sign that you're in for a demography problem, yo.

In his latest video, "Love The Way You Lie," starring Megan Fox and Dominic Monaghan (Charlie from Lost) Eminem raps about what everyone is calling an abusive relationship. Stop. When you hear the words "abusive relationship" what do you think we're about to see?

a) guy beats girl
b) girl beats guy
c) they beat each other

You probably amended your answer as you read the choices, but grant me that most people reflexively choose a. The Huffington Post did: "Megan Fox Abused in [said video.]"

The video is decidedly not about that kind of abusive relationship. Megan Fox throws the first punch-- while Dominic is still asleep. And the second, and the third through the tenth, and pretty much all of the punches. The first 55 seconds of that video can be aptly retitled, "This Crazy Bitch Is Crazy, Why All These Bitches Gotta Be So Crazy?"

This didn't stop a lot of people from holding this up as an example of male aggressor domestic violence, and that is because they didn't really watch the video, they saw a guy in a tank top and went to Defcon 1.
In fact, the only people Dominic Monaghan does hit are a) a wall; b) some American Eagle wearing mofo in a bar; c) a mirror.
Ok, ok, not totally true: he does hit Megan Fox once at 3:45, and if I am interpreting this video correctly, it is because she was asking for it..

II.
Slow down, I hear you, check your prejudgmentices at the door.
What Dominic (and Eminem) do a lot of is talk tough. Threats, yelling, intimidation, punching objects, "I'm feeling a lot!" these are the tools of male weakness, aptly embodied in Dominic Monaghan. I liked him in Lost, but is anyone buying this guy is a physical threat to anyone? Not wearing a shirt only makes you look like a better fighter, but you'll still need to sneak up on your target and hit them in the face with a bottle. This next sentence is 100% accurate: I could take out Dominic Monaghan, Megan Fox, and Eminem, all together, even if they were all armed with toasters and I was asleep in a bathtub. This isn't bragging, it's just that tattoos don't actually make you strong or else every girl I knew at the beach was a superhero.
"I guess I didn't even know my own strength," says (Eminem speaking as) the abusing boyfriend. Nope, that's what you want me to think, because you don't want me to realize that I just witnessed your maximum strength. Bristle that fur, wildman, bristle bristle. "I'm a man, STRONG, yes I hit you and it was wrong but you should also know that I restrained myself because I love you, if I really let my anger out you wouldn't stand a chance." Yeah, yeah, you'd have to sucker-bottle me first.
In these relationships, the hold over the woman isn't physical, it's nourishing. The song isn't about Domestic Violence (capital letters, you are in the presence of a construct) but about a kind of love that substitutes magnitude of emotions for quality of emotions because that's the next best thing. I don't mean this next part as an insult: toddlers do this. They want you to extra love them up, but if you're watching the Radiation King they'll not hesitate to lick an electrical socket to get attention. They would rather you yell at them than ignore them, and that emotional charge they get temporarily sustains them. Spam isn't ham, but if you're starving it'll do. And yes, eventually you will get used to, and even like, Spam. It is repetition compulsion and it is inevitable. Look, in the video Dominic is strolling through the vodka aisle and he can steal anything he wants and he chooses to steal... Stolichnaya. Freud was right.
This is why it is so hard for women and men in such relationships to leave. Yes they are afraid but the real fear is abandonment, starvation: this is your whole life, how do you walk away from everything you know? You know it got violent yesterday, but you also feel emotionally full: the contrast between yesterday's anger and today's teddy bear gift is so gigantic that your emotions top out, like cocaine or winning at blackjack. The absolute value of that love may be much less than "a good man's," but he can't provide the differential. That's the toddler problem.

Asking them to stop battling each other is to ask them to fast, what should they do when they get hungry? They both feel no one will ever love them as much, and dopamine or whatever is going on in their brain confirms it. While you're yelling from the outside "get away from him!" from the inside they try to deflect with high emotion substitutes: drugs, pregnancy, cheating. After a while, your life is that cycle. You can break up, sure, but each of you will probably repeat that pattern elsewhere, because the problem isn't the specific partner in front of you but the way you sustain your relationships. And when you both work off the same patterns, you'll be together ten years longer than you should be. When you're hungry, you gotta eat, and you may have heard of hunting and cooking and peeling garlic but Spam is SO EASY and you know EXACTLY how to get it. Bonus: it now comes with Stoli.
The only solution I have ever seen work is that one of the people has to change the way they respond to the other. You hate me when I bring up certain topics, so I'll give you a parable;   one thing I've noticed about the mutually abusive is their clinging to spirituality because when you live by no rules the psyche demands you to impose them from without:
And when the toddler comes ferociously upon you and yells, "I AM TWO AND I AM UNCONTAINED!" do you beat him like a dog? Teach him that the rest of your life will have to wait while you unleash your anger on him-- so central is his existence? Or rather, do you calmly show restraint, neither do you reward his mania with your emotion? They are filled by your love, but they will settle for your attention. He who feeds a Chaos will raise a Demon.
I'll let you work out the details for adults.

III.
Let's just dispense with one thing, formally, right now: hip-hop is not a periscope on the black experience, and Eminem is evidence. This isn't to say that it may not speak to/about blacks, but it speaks to Kansas white girls a whole heck of a lot as well. The myth that Top 40 hip hop is still black is mostly perpetuated by culture writers who a) have no other contact with blacks whatsoever, and desperately need this as a source of information and to pretend to be diverse; or b) culture writers who don't like blacks, don't really know why they don't like them, and need an easy target.

Here's an example, and I hope my terrible writing skills will be able to effectively articulate this because it is extremely important.

Here's how a writer at The Atlantic describes the video:

I suppose I genuinely sympathize with both of them. Rihanna went through a public, awful domestic violence incident that she's clearly tried to work through
Note the exaggerated "awfulness." The only person who would describe it that way is a person with no personal interest in it. How do you know it was awful? I'm not saying Rihanna liked it, but... isn't Rihanna saying she did? Isn't that the whole reason she is in the video in the first place?

Her (the writer's) thinking is infinitely narcissistic, it refuses to even attempt to understand the experience from the other person's perspective because it does not CARE. Of course it was awful, but what, precisely, did Rihanna think about it? This thinking chooses a label, and then tries softening the use of that label by feigning outrage or sympathy. You'll see it often/always when race is the topic; an earnest by self-absorbed white person will reveal their unconscious racism but hide behind their progressiveness and intellect:

"We're being ironic!" No you're not, you're idiots.

Here is the primary difference between The Atlantic's perspective and Eminem's audience's perspective of the video: to the former, the video is a discussion of an issue; to the latter, it is CCTV of their lives. And probably a routine Thursday at the Inem house. It is too real and too usual for them to describe it as an "awful domestic violence incident," any more than they would describe their dinner as "a reliable spaghetti scenario."

The Atlantic writer discusses the song in that same superficial, deeply ignorant, aloof manner.

But this just feels incredibly self-indulgent. Eminem's slow. Rihanna's autotuney.

That's written by someone who needs to pretend to like hip hop music, i.e. a poser. "The wine has a smoky, fruity aftertaste." ? "The painting was minimalist but jarring, an amazing use of color." ?? But why do you have to pose? You don't have to like hip hop, or understand it, to write something about it; you could simply write as an outsider, "look, I have no idea what the hell I'm looking at, but here's what I see" and still give the reader something valuable; but the reason she is writing isn't to teach the reader anything but to convey the impression that she is a serious critic of hip-hop. She's not writing for you, she's writing for herself, for her identity. This is how she began the article:

I tend to be a defender of Eminem's poppier impulses, as long as they make good use of his skill set.

This is when I reflexively bit through the neck of my rum bottle, yes it hurt, but it saved me from a stroke. This woman doesn't really care about hip hop, though I'd bet big stacks she truly believes she does; and she doesn't really care about domestic violence though I'd double down on those big stacks that she really, really, believes she does. It's all a show.

Eminem has no interest in glorifying domestic violence. He is speaking to the majority of his audience who completely, utterly, deeply "get" the song:

"This song completely changed my life"
"I love this song"
"I want a relationship like this, intoxicating just like a drug"
"I know every word"
"there's no words to describe how much your music turned my life around and also saved my life"
"this song, so deep, so awesome"

And that's just the women.

This song isn't about Domestic Violence, it's about people.

IV.

Why does the song have to be about "Domestic Violence" anyway? Why can't it just be about two screwed up people, one of whom is a soccer hooligan? Because there are certain themes that are not allowed to be merely depictions-- they have to be about "awareness" and "sending a positive message." Domestic violence is one of those things, and before you say anything observe that homicide is not one of those things. Neither is adultery or cannibalism. We choose our causes based on something other than the cause.

Yet you're going to find a lot of people who can't wait to say: "it's not a positive message to send to kids." Fine, but this is when you pipe up? Someone on the Huffington Post used this video to offer up the warning signs of domestic abuse, here they are for your education: Jealousy, Controlling Behavior, Blames Others, Cruel, Past Battering. I stand vigilant. Prior to revealing these insights, said writer includes this caveat: "remembering that though these warnings are written in the guise of straight man/straight woman, abuse knows no gender or sexual preference boundaries. " That's what she needs to tell you, "I'm sensitive to lots of things, battered women and sexual orientations," that's where her head is at. The article has no value in preventing Domestic Violence, it is all about identifying her.

I may not like Eminem's music, but I am able to see how his lyrics speak to a lot of people that no one else is speaking to, unless it's down to. If you want to know why there's Domestic Violence, that's why.

V.

Maybe you can't feel the song because you don't have a personal connection to that kind of relationship. Ok, let me use a different example. There's an other video, Airplanes, not Eminem's but he does rap on it:

alright lets pretend Marshall Mathers never picked up a pen
lets pretend things would have been no different
pretend he procrastinated had no motivation
pretend he just made excuses that were so paper thin they could blow away with the wind
Marshall you're never gonna make it makes no sense to play the game there ain't no way that you'll win
pretend he just stayed outside all day and played with his friends
pretend he even had a friend to say was his friend
and it wasn't time to move and schools were changing again
he wasn't socially awkward and just strange as a kid
he had a father and his mother wasn't crazy as shit
and he never dreamed he could rip stadiums and just lazy as shit
fuck a talent show in a gymnasium bitch, you won't amount to shit quit daydreaming kid
you need to get your cranium checked you thinking like an alien it just ain't realistic
now pretend they ain't just make him angry with this shit and there was no one he could even aim when he's pissed it
and his alarm went off to wake him off but he didn't make it to the rap Olympics, slept through his plane and he missed it
he's gonna have a hard time explaining to Hailey and Laney these food stamps and this WIC shit
cause he never risked shit, he hopes and he wished it but it didn't fall in his lap so he ain't even hear it
he pretends that...

You can complain about who is glorifying what and how someone is being represented as whatever, but in doing so you ignore the millions of people-- kids-- who are feeling neglected by you and represented only by Eminem et al. If you focus on Domestic Violence and miss their internal struggle, then you will neither stop Domestic Violence nor affect their lives, and they will abandon you. They already have.

Maybe this song doesn't speak to you, fine, okay, but trust me on this: there is someone who is hearing it, and if you are hearing it, it's for you.

---

More on rap music: Jay-Z

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Lunar Cycles and Psychiatry

Addendum 11/15/06: Fair is fair. I found an even better review by one Eric Chudler, PhD at Univ. of Washington, called Neuroscience for Kids. (don't laugh). I didn't review all the links, but it is certainly more comprehensive than what I have here.

You know how everyone says that people go insane when there's a full moon? Well, I looked it up.
Most studies finding a link vbetween violence and the moon were done in the 1970s. For example, a 1978 study found a lunar relationhsip to everything-- suicides, asssaults, MVAs, and psych ER presentations, with both homicides and assaults both occurring more often around the full moon. Then again, you have to be suspicious of any study that actually tells you they actually used a computer.
But by the 1990s, this lunar relationship was on the way out. Consider a 1997 study in Italy found no relationship between community psych contacts and the moon phases. A 1998 Australian study found no relationship between violent episodes in inpatient psychiatric patients and the moon phases. A Spanish 2002 study found no link between ER presentations for violence and the moon's luminosity. A German 2005 study found only the weakest link between completed suicide and the moon (the new moon, mostly.) A 1992 Canadian study reviewed 20 studies covering 30 years and found no link to attempts or completed suicides and lunar phases. And, to prove a point, a gigantic Austrian study in 2003 found no relationship between lunar parameters (phases or sideric) and any ER presentations.
Which brings me to one point-- do Americans do anything other than drug studies? Well, one non-clinical study was done in Texas and found no link between prisoner violence and lunar phases.
---
So it is with violence and suicide. But what about other behaviors? I haven't had time to investigate the question, but two studies are suggestive. One (British) 2000 study found a slight increase in presentation to family practice clinics during full moons that was not due to psychiatric symptoms. An Austrian 2003 study found a strong relationship between thyroid clinic appointments and dates around the full moon. And a strange (British) 2003 study finding that women called a crisis center more frequently on the new moon.
I did find an interesting (Greek) study finding an excess of seizures on full moons (34% vs. about 21% for the other phases.)   Importantly (and in contrast to suggestions by other studies) these were not pseudoseizures, because all patients were monitored. The authors speculate either electromagnetic/gravitational effects (hey, it could happen) or an interaction between the intrinsic seizure threshold and the environment (i.e. you can change your own threshold.)
My interpretation of this is that the moon can't affect your behavior directly (duh), but one's relationship to lunar cycles could influence your behavior. Take the classic wolf and full moon relationship.    Prey animals, such as rats, generally reduce their activity during the full moon (don't want to get caught, I guess.) Wild maned wolves (which eat rats) travelled significantly less during the full moon. The authors' explanation was that prey is less available, so wolves would want to conserve energy. Additionally, maybe one reason why so few studies are American is that we have a lot of artificial night light, so the moon has less or no influence, while elsewhere there is less artificial light? Who knows. I'm going to bed.

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===== ====== ===== The Last Psychiatrist: Luxury Branding The Future Leaders Of The World

do you see?

Want to go buy a $10000 watch? "In 2009-14? Hell yeah, let me get my coat."

Watches have the same problem diamond jewelry has; it better be beautiful enough to keep forever, because if you try and sell it you'll discover there is no secondary market for it. No one wants the necklace your ex had waiting for you when you got back from Cozumel. "I've been doing a lot of thinking," he says, "about how easy it would be for you to get all the penis you want. Let's get married and make sure neither of us are ever happy. No, no, moving closer to your parents doesn't sound like a bad idea." Turning it into an heirloom keeps it out of the market and the supply stays regulated by the manufacturers, which I think is collusion but I'm no lawyer.

These ads can be seen in whatever rich people use to relax on Sunday afternoons, e.g. The Economist.

This is a brilliant campaign, for technical and artistic reasons. What is the brand that it conveys? Heirloom quality.
The ads use black and white photos: we've been around for a long time. Even the advertising campaign self-referentially broadcasts this-- it has been the same since 1996, i.e. longer than a 40 year old has been in the market for an expensive watch to notice it wasn't always thus, reinforcing the longevity of the brand.
I know you probably figure this ad isn't for you because you're not a railroad baron or a Rothschild, but ask yourself a question: have you seen this ad? Then it's for you. Time to learn why they know you better than you know yourself.

I.

The demo for this ad isn't the Rothschilds or the 1%: they don't buy based on ads.   And they don't need to be told what constitutes quality or authenticity, they can tell, that's what boarding school was for. Everyone else is going to need to be hit over the head with the semiotics of quality--

i.e. see an ad campaign about those signifiers. Oh, I get it now, this is a fancy watch.

The target demo is not the 1%; the target demo is the Aspirational 14%. They know they are supposed to like quality and goodness and etiquette and discretion, but no one ever taught them what those things look like, so when someone does point it out to them they will go all in. Hence: anything in Trading Up. And they don't care about the next generation. Not really. They don't want them to be eaten by zombies but anything past 2069 is of no consequence.   What they do care about is how a product brands them, what it says about them now, now that time is running out. Can't afford to be subtle, which is the same thing as saying I'm willing to pay $10000 to get the message across. There's a difference between what the brand is and what the brand says about you. You'll pay 10x for the former and 100x for the latter.
Most products have quick, easy, memorable taglines, because most people are idiots. However, Patek Philippe's tag line is complicated and unmemorizable:
You never actually own a Patek Philippe. You merely take care of it for the next generation.
Which is the kind of tagline a person who wants to be a wealthy, complicated, precise man who doesn't fall for tag lines would fall for. The man in the photo is not a representation of the target demo; he is the impossible aspiration of the target demo.   That explains how the kid can be in a sweater vest and not trying to murder his family.
The ad is pairing the legacy of the watch with the other imaginary legacy: the heritable family fortune. I don't know what the Dad in that picture does for a living, but you can be sure it involves a lot of money and the son will inherit it, along with a boat (below) and the means of production (not pictured).

Also not pictured is $15T in debt and war with Iran, which he will also inherit, though he'll only be responsible for the former while the bottom 29% will only be responsible for the latter. Sorry folks, that's how it works, take it up with the Illuminati. Dad is teaching the son the things a man should know, like how to tie bowlines, which Aspirational 14% didn't actually teach their own kids, which, and I hope you are appreciating the pattern, is precisely why this ad works. It's not representational, it's aspirational, i.e. can be done from the couch. "If I had a yacht, I would definitely teach my kid yachting. Time for a nap."
Some Patek Philippe owners do indeed know how to tie bowlines but the majority of potential customers are close-but-no-cuban to these aspirations, they wish they had enough to start a family legacy and get their name on the backs of orchestra programs because that would mean that they go to orchestras, that they are sophisticated, they have made it. Not Hollywood and dotcom made it, which was what they dreamed about twenty years ago, but the kind of made it where last names matter and "summer" is a verb.
You can't buy into class but people will try anyway, so the watch gets the nouveaux and nouveauxing rich as close to this lifestyle as they will ever get. Not only is it a visible symbol of their success but it broadcasts (as per the ad) that they are the kind of person that reflectively considers the next generation, what they will pass on to them, their legacy. (1)

"But don't they already have money to pass on?" It's not the money, but everything else but the money. Ryan Gosling's character in Drive inherited nothing from his dad except a Patek Philippe watch, but because it is a Patek Philippe we are to understand that it symbolizes the real gifts his Dad left him, like masculinity and courage and driving skills. The watch symbolizes the intangible legacy gifts that came along with it, but in real life there are no intangibles to pass on, so it is being used instead of those intangibles. It replaces the intangibles.

If this is confusing, remember that the watch is for the father. The point isn't to give it to the kid, the point is to convey the impression that he is going to give it to the kid. To convey the impression that he has other things to leave to the kid as well, just like those other high class Americans who pass on connections or defense attorneys or the Greek Prime Ministry. That's the kind of man he is.

It may also help to understand that Patek Philippe is not here competing against Rolex or Breguet; it is competing against vacations and cars and kitchen renovations. That's where $10k might have gone, so Patek must brand itself as an important generational necessity, a marker of European-style class, not a frivolous transient American-style expense.

This is the motivating force of Aspirational 14%: they have some money, wish they had a lot more, and want an ethical rationalization for their envy: it's for the kids. Keep telling yourself that. Dynasty is the wish-fulfillment of immortality through your bloodline. But it's better than nothing.

II.

Then the Great Crash happened. How did the ad campaign change to reflect the new economic realities?
The answer is in the above ads: there's father and son. What's missing? Mom. Doesn't she want a watch? Starting in 2009 she does, so tint the B&W to sepia and let's see what else modern women want.

Nothing symbolizes the essence of a woman better than looking at herself in the mirror. "Something truly precious holds its beauty forever." A tag line even a Wellesley graduate can remember.

Older woman's left hand conspicuously assures us she's married. The younger woman's conspicuously hidden in the mother's hand.   Mom maintains control of the daughter's sex.

In these ads the legacy is quite different: not wealth, or the business, or dynasty, but the hopefully enduring commodities approved for use by women: beauty, art, joy.   It's mom and daughter and love, packaged in refined ostentationism, which is defined as subtle quality visible from 1000 yards. Not pictured is Dad, because he's at work or one of those parties in Eyes Wide Shut.
A Financial Times reporter incorrectly interpreted this as an expansion of the campaign to target women. This is where my training in neurology is helpful: precisely where in the brain did the stroke have to occur to cause that kind of deficit in logic? Expansion? In 2009? That makes no sense: expensive jewelery, like a car, is almost always purchased by or with the husband. The wives of the Aspirational 14%, even if they have good jobs, do not roll into a jewelry store by themselves and buy $10000 watches, unless they are the 0.5% or it is a present for their man.   Hence, this is an ad for men, not women, which is also why this ladies' ad is prominently featured on the back cover of The Economist, the journal of record of Aspirational 14%, a magazine with 90% male readers. Through the triangular magic of Freudian advertising you, the viewer, become the Dad, with the aspirational images laid out for you: a beautiful and proper wife with culture and delicacy, taking care of your perfect daughter, while you're in the shower scrubbing the scent of concubinage off you. So my silly joke was wrong: she's not a Wellesley grad, she's a Wellesley trophy wife. The Wellesley lets you both pretend you married her because she was smart.

III.

Something else about these ads: men and women never appear together.

Here we see the explicit pairing of same-sex members, never a family. They both get a watch but what the son inherits (everything) never overlaps with what the daughter inherits (a husband). "But that's how the watch will be passed on." Haven't you been listening?   These are brand ads, not product ads, they sell the aspiration, and, if I am reading this right, that aspiration is to become European. Not Eurozone European, of course, but Hapsburgs and Romanovs European.

Do these ads appear sexist to you? (2) Shouldn't some "intellectually curious" (the explicit demo of The Economist) woman somewhere notice the contrasting aspirational message between the men's ads and the "ladies''"-- and that word itself is a kind of branding-- ads? But 40 years after women's lib, this isn't such a terrible fantasy to women, either. They might not want to give up their job as a CT surgeon, but they may happily abandon their job as employee of MegaCorp if they could afford to. That's the fantasy, and this high class ad in a high class mag is saying high class women not-so-secretly want this.
Why reveal this desire now, in 20XX? Hmm, isn't it weird how just as soon as women entered the workforce it became completely impossible for a family to achieve the American dream without the woman in the workforce? Turns out that part of the drive to get women into the workforce was driven by... the workforce owners. Get it? Whenever you don't understand geopolitics just ask yourself where the lowest labor costs are, and wait for the headlines to read "human rights issues."
Of course women should be paid the same and should do whatever they want, but the point here is that that is a coincident benefit, the other purpose of it is to have a larger pool of labor willing to do jobs too good for Mexican illegals and not good enough for American men, i.e work in retail.   Is it really liberating for women to work at Bebe but not be able to afford to shop at Bebe? Or is it just stupid, except for Bebe, which derives the full value of their employees' sex for $12/hr?
Here's an example: there's a dwindling but vocal segment of the female population that thinks that young women in the office should not have bare legs, that it is too sexualized. Bare legs are okay if you're a gold-digging whore, but "inappropriate" if you want to be taken seriously as a professional woman. Simultaneously, however, they believe professional office attire should be heels and a tight skirt. "It's called a business suit." It never occurs to them that the requirement of hose/stockings in the office was started way back when it was stockings, not bare legs, that was sexualized. You can go as far back as a Bob Hope movie where a sailor gets his best gal a pair of nylons (swell!) all the way to the 1986 scenes of Kim Basinger masturbating to a Kodachrome art show or stripping to the worst song ever in 9 1/2 Weeks, the intense eroticism depicted not by her naked body but by close up shots of her stocking covered thighs.

Once upon a time stockings were so fetishized they put them right into movie posters, nowadays the only place you're going to see them is MILF porn or all of Britain. And so the prohibition against bare legs has to be rethought-- is the worry that some 20 year old guy is going to get internet hard if he sees his coworker cross her bare legs? Who cares what 20 year olds think?   The non-Lacanian, non-postmodern, super-duh conclusion is that the (male) office wanted their women all dolled up-- the trick, however, was that it convinced women to self-enforce this trend, to believe that the stockings helped de-sexualize the professional women, gave the power back to the women.   No one man could pull off that kind of mass hypnosis, it has to be programmed into the Matrix. The system at one time wanted the office woman to be a simulacrum of a woman, all silhouettes and shades and posture, the stockings looking more like an idealized pair of gams than real gams ever could. Burning the bras wasn't nearly as liberating as getting rid of the pantyhose.
This is why the return of pantyhose is so revealing; hose represents a return to that sublimated female sexuality; to the more dangerous implicit, not explicit, masculine control of the sex. It isn't just like the 1960s, it is a retreat to the 1960s.
"Mr. Davis can't trust himself around you if you're naked," says the Human Resources department for a 50 year old mustachioed small business owner, "so if you don't mind we'd like you to cover up with this sexy lingerie. Thanks, you're a doll, now he can get some work done. He's going to need you to work late tonight. No, he'll drive you home after."

IV.

Back to Patek Philippe. That The Economist would want Patek Philippe to buy advertising space makes sense, it's good money, it decorates the pages of The Economist, and attracts an important demo that will pay the $130 subscription fee (the higher price is the magazine equivalent of the Patek Philippe Seal). This demo has made The Economist one of the only magazines to see a consistent growth in print subscriptions. And it's part owned by the Rothschilds. How do you like that?
But what is interesting is that Patek Philippe thinks the readers of The Economist are a good fit for this campaign. Are they insane? Perhaps not. On the one hand The Economist is an intelligent magazine that does promote free market, free thinking, "liberal" values in a mostly non-partisan way; but if you imagine a magazine's ads as the unconscious fantasies, the dreams, of the readers, then the wish fulfillment they depict is not riches or bitches but a return to the old feudal order.
What you are seeing is the slow acceptance among an important demo, Aspirational 14%, of rigid class divides. They may have some lingering disapproval about income inequality, hedge funds and genetic engineering, but it is tired of fighting a losing battle and you know what? all men aren't created equal, science keeps saying so and we pay our athletes accordingly, why not everybody else? Aspirational 14% doesn't want a monarchy, but they sure as hell don't want democracy, not the American kind, not anymore. I know, I know, you're rolling your eyes, you don't care what the readers of The Economist think or want, but the trouble is that as compared to the readers of Wired, Time, or The Atlantic, The Economist readers are more likely the ones who are shaping the new world order. That's why the classified ads in The Economist are for CEOs and the ones in The New Yorker are for mental institutions.

It is a sleight of hand on the American dream, and it's been a decade in the making, the Great Crash only accelerating it. On The Apprentice the big prize is a Rolex and a job with Donald Trump, but the person evaluating you for that position are two generations of Trumps, take that American meritocracy! There's no illusion you can become a Trump, the best you can do is become a wealthy employee of Trump. And you'll take it. But if The Apprentice is indeed a metaphor for this European feudalism, then you should observe that the show's original judges were Donald Trump and his business partners (=American capitalism); Trump's kids were a later addition. The evolution of the show was towards dynasty, not away from it, just as the Patek Philippe ads have moved, after 172 years in the branding business, towards this:

--towards this, during a time of social and economic upheaval, flattened earths, "student" revolutions in many Middle East countries and all out wars in many others; towards this, during the time the most important person in Europe is a woman; towards this in the pages of higher brow magazines for the "intellectually curious."

Anyone who thinks the profound changes happening in the world now are going to result in greater democracy or equality is not reading The Economist as carefully as he should.

----

1. This is also why I think college tuition is likely to remain high for another generation. While government loans are primarily to blame for the complete disconnect between the value of college and the cost of college, parents represent a significant part of the demand. Lacking any other inheritance to give them, it promises to get them as far as college with college prep classes, violin lessons, (unpaid) internships, etc.

2.
If you want to know what an aspirational image for a "ladies'" luxury watch targeted to actual ladies looks like, i.e. what women who will buy this watch want to think of themselves, you have to roll back the chronometer to 2003, back when the biggest crises facing the world were stem cells and Muslims:

Forget the watch, why do I suddenly want to buy shoes? (Because nothing says "I can be someone new" like new shoes.) The campaign was started in 1999 to target 28-35 year olds, but how many of those women could actually afford a Patek Philippe? Zero, hence the genius of the ad: build brand awareness. "We'll see you at the store when you're 40 and rich," the ad proposes, though it tacitly admits that a woman can't think more than 24 hours into the future unless it's to imagine becoming a trophy. Wife. NB: these women would be 40 now and on their second husband/watch.
Speaking of marriages, note that the single tweak necessary to distinguish the American vs. European ad campaign is to hide the wedding ring, Inception style, so you aren't sure.

In an American ad, if a woman is possibly going to have sex, she better not be single. In Europe, she better be.

---

See also: If the rich youth can't get jobs, it means socialism has failed.

-----

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Major Depression is Major Depression, Until Proven Otherwise

In which Marco Polo is forced to agree that a unicorn is a unicorn, until proven otherwise.

Ronald Pies gives a critique of the Horowitz and Wakefield book, "The Loss of Sadness." (This is the same book Dr. Nasrallah dismissed in an another editorial.)

His article is very good, and aptly represents the "con" position to Horowitz-Wakefield's thesis that that normal sadness has been pathologized into MDD.

Pies summarizes his position in bullet points at the beginning:

does bereavement predict a benign, self-limited course even when the person meets all the criteria for MDD?
does MDD in the context of bereavement differ, and respond to treatment differently, than typical MDD?
do psychiatrists have any way to fairly judge what is proportionate and disproportionate grief? Are there clinically validated instruments to do this?
And since the anwer to these is no-- there is very little evidence for such distinction between bereavement-associated depression (BRD) and typical MDD, one should not attempt to make such a distinction: MDD, when it fits the criteria, is MDD. Go.

I.

Putting aside any debate as to whether or not Pies is right, a more important question is this: do we want him to be right?

We should not be too quick to pathologize, even when there is pathology, because pathologization reflexively diminishes the individual's ownership. Not just their "responsibility"-- that they had a hand in the pathology, and have a hand in the treatment (not as blame but merely as description of events) but also their identity. The moment sadness becomes MDD, even legitimately, it becomes less something that is them and more something that occurred to them. Grief is my response to loss; MDD is my body's response to loss. That's a big difference. The quick retort is that MDD does not seek to reduce identity ownership of "symptoms." Maybe-- but it does anyway. A second retort is that this reduction is a good thing. Again, maybe, on a case by case basis, but as a general axiom for humanity, it can't be.

II.

But aside from abstract ideas about identity, the main thrust of Pies's argument is the lack of evidence for a distinction between BRD and MDD.

...common sense might tell us that bereavement related depression is a normal, "adaptive" response to loss, whose "biology" and response to antidepressants would differ considerably from that of standard major depression. This is all quite common sensical-- and all quite qwithout convincing evidence.
Does common sense say that? I assume he means "common sense would say bereavement wouldn't respond to antidepressants," but response to "antidepressants" is certainly no criterion for making a diagnosis.   We're not even sure that SSRIs work for typical MDD, let alone bereavement-- consider the hardly impressive 10% improvement over placebo-- even as 50% of studies in which SSRIs don't beat placebos lay unexposed on the laptops of a hundred tenure track academics like so many unerased browser caches: a little guilt, a little embarrassment, a lot of denial. "That didn't really count." Honi soit qui mal y pense.

And response to which antidepressant? MAOIs? SSRIs? Seroquel? All of these FDA approved antidepressants tell us nothing about the underlying pathology, if it even is the same pathology. It doesn't even tell us anything about antidepressants themsleves. The fact that only Wellbutrin worked in one guy and Zoloft in the other doesn't suggest that MDD can have multiple treatments, but that those two guys have different problems. Consider, in 2001, a patient with pure MDD is treated with Seroquel monotherapy. Do you say Seroquel is an antidepressant, or do you say the guy's "real" diagnosis was bipolar? It is only an accident of history that Seroquel is an anipsychotic now indicated for MDD, and not an antidepressant we later find out is an antipsychotic.

If otitis media resolves because of antibiotic treatment, does that mean that it was bacterial? And if we later discover that it was indeed viral, does that mean that the antibiotic actually did nothing? Are you sure? Sometimes we discover medicines do things we didn't know about; sometimes there is placebo effect, which still counts as the medicine doing something; sometimes what you think is the actual medicine is decoy: valproic acid was originally simply an organic solvent, once used as a vehicle to test novel antiepileptics.

The fact that I can knock 12 points off a Hamilton Depression scale with an Ambien and BID Krispy Kream should serve as a warning about the validity and generalizability of the term "antidepressant."

Psychiatry can live with unknowns as long as it doesn't try to assume pathology by the presence or absence of efficacy. So I agree with Pies-- you can't assume SSRIs won't work in BRD. But I also disagree: so what?

III.

Pies makes a mistake many doctors make: choosing science that suits a social agenda. This isn't malicious, he is doing it as a healer, in the service of humanity. But it is an agenda nonetheless. The entire article's logic and evidence is solely to promote a single idea that finally appears in the last sentence:

It would be tragic if we inadvertently discouraged recently bereaved persons from seeking professional help, on the dubious presumption that that their depressive symptoms are merely "normal adaptations" to loss.
That's the main concern: that we don't discourage people from seeking help, that we don't turn people away because we think they don't have MDD.

It's possible that he wrote this in 1955, but a cursory examination of the state of affairs in 2008 fairly quickly makes evident that quite the opposite is the current state of affairs.

Are we in any danger of not treating people who want it? If Pies accepts a broad definition of treatment to include non-antidepressant treatments, e.g. therapy, sleeping medications, etc-- does it happen ever that psychiatrists turn patients away at the door? "Wait, wait-- all this is because your husband died? Get the hell out of here, you abuser of the system."

Certainly I can agree with him that more rigorous application of the criteria would help formalize who gets and does not get treatment; but simply to the question of whether we face a dire emergency of undertreating sadness-- whatever we later decide to call it-- seems to contradict reality.

Even if we grant his worries that it could happen that we turn people away, it isn't at all evident that doing this harms humanity. On the one hand is the not well founded belief that our treatments actually do anyone any good-- see above. "Depression is a lethal condition." Ok-- what reduces that lethality? Not antidepressants, as far as I can tell. Etc. And depression isn't always a lethal condition, indeed, it is rarely a lethal condition. Lung cancer is a very lethal condition, but there is no rush to assume that chronic cough is cancer, even if they smoke 3 packs a day. There is nothing, beyond an odd claim to individual rights, to gain from allowing coughing smokers to buy more cigarettes, but there may be quite a bit to gain from not pathologizing bereavement even when it is MDD. It doesn't mean we can't help them-- and this is indeed Pies's point-- and we should help them, maybe even give them an SSRI-- but that act must be done in the context of bereavement, not in the context of depression.

As if to reinforce my point, Pies writes:

...on the dubious assumption that their depressive symptoms are merely "normal adaptations [sic]" to loss.

It's hard to tell if he meant to do this, or it was a slip, but note his word choice. The correct word should be "adaption," not adaptation. An "adaption" is a change in response to surroundings, events. An "adaptation" is the process of adapting, it is what increases evolutionary fitness in a species. It doesn't help that single organism, it helps the species. In that context, how society grieves could be an adaptation; but making it MDD precludes that possibility because we define it as not beneficial to the species.

IV.

If the purpose of the criteria is to make the diagnosis, then we might want to ask what is the purpose of treatment. Assume someone with BRD was treated such that within, say, a month, all of their symptoms resolved. Completely. Would you call that a treatment success, or a treatment failure? Only one of those is defined by the current system of psychiatry.

V.

Pies attacks the concept of a "trigger" for depression. It looks like the depression came as the result of the recent death, but who knows? We often assign a trigger in retrospect, but that may simply be the mind retrofitting a cause, and not actually observing observing a necessary connection. Well played, Dr. Hume.

I agree: ignoring issues of causality and focusing only on the criteria would be both fair and awesome except that the criteria lead to a diagnosis about which causality is implied: amines, genetics, and the like.   It's one thing to debate whether BRD and MDD share similar biology, or not; but it isn't at all evident that cases of typical MDD share common biology, or biology at all, yet that is precisely what is assumed. Does every person with MDD have a genetic basis for it?   Yet no psychiatrist ever says, "this is MDD, but I doubt you have a genetic predisposition."

The problem is that such assumptions of biology-- even if they have basis-- create social and legal obligations. Example: until you have hard evidence to the contrary, you want it to be bereavement, not MDD, so that you can't be involuntarily committed for it. You want the commitment to be about the possible dangerous behavior (e.g. evidence of suicide) and not at all the about the diagnosis. You say: but we don't commit people for being depressed. You don't. Today you don't. But tomorrow? Don't make the Fundamental Error Of The Dumbest Generation of Narcissists In The History Of The World: today is the end of history. We once thought homosexuality was a disease; today we don't; and one day we will think so again. It is inevitable. Science is almost never fast enough to prevent the mission creep of our own prejudices.

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===== ====== ===== The Last Psychiatrist: Man Convicted Either For Child Porn Or Nothing
You decide. Make sure that once you pick, you accept the logical consequences of your choice.

Britain-- where they have more surveillance cameras than jobs (sadly, zing)--

A man has made legal history as the first to be sentenced for downloading "Tomb Raider-style" computer-generated child pornography...The pictures were part of an illustrated story involving child abuse and incest - but involving no real children
Computer generated still pictures.

The pictures on which Hoque was acquitted were "almost comic strips" with speech bubbles, the court heard.

The six pictures on which he was found guilty were so realistic, the jury concluded they looked like photographs.

No one thought he had molested anyone, and it appears no one even thought he was going to. But the pics are more like heroin, the more you use, the more you want, and maybe then you might become a molester:

"I think you'll get some insight into the damage that children can suffer. This may be on the fringes of it but it's still an entrance, a door into a very murky and distasteful world." [said the judge.]

The problem with this argument is that it doesn't fit the reality. Are you sentencing him for possessing the pictures only, or because it leads down the path to wanting more? Because he already wanted more:

They were among tens of thousands of images on his computer hard drive seized by the police in October 2006, ranging from crude, simple illustrations to cartoon images to complex graphics.
Most were "fairly distasteful and disgusting, but perfectly lawful", said the judge.
In other words, if he had the tens of thousands but not those six, is there no concern? If I had those six, but not the other ten thousand, would I get the same sentence?
You have no idea, really, if it leads to molestation, that argument is a red herring. If it was actually the real concern, then this would not have happened:
The judge did not ban Hoque from working with children.
The problem with policing a thought crime is that we can't agree on what is a crime, let alone a thought. And if you don't have the legal or physical ability to forbid someone from performing a physical action (e.g. work with kids) how do you plan on forbidding them from thinking things?
These are not real kids, this is CGI. As abhorrent as it may be, you can't regulate thought on the assumption it leads to behavior. It is impossible to ask how many virtual child porn users molest. There's no way to verify either.
You can't argue that fake child porn will incite them to molest kids; legal porn wouldn't get them fired up as well? Or the KMart catalog? Or a visit to the playground?

Almost Supreme Court Justice-but-instead-we-got-Kennedy Robert Bork made the argument that pornography, especially child pornography, doesn't deserve to be protected speech anyway. Carefully, he hedges that while the government shouldn't have the right to outlaw such "speech," neither does it have the right to prevent segments of society from curbing it themselves. Supporting this nuance, he us that porn as a first amendment issue is a relatively new discussion, despite how the First Amendment, not to mention porn, actually is.

He's right, but he's perhaps purposely avoiding the question of whether it is ok to punish real people for, in essence, looking at stuff.

As I've said elsewhere on the same subject, don't confuse my neolib sentiments for actual lib sentiments: if you want to prevent child molestation, make it a capital crime. But the focus has to be on the act, not the thought, because you can't measure the thought, neither does it translate clearly into act.

(Older post on pedophilia.)

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===== ====== ===== The Last Psychiatrist: Man In Coma For 23 Years Not In Coma

Story: Man in "coma" for 23 years,

Then a neurologist, Steven Laureys, who decided to take a radical look at the state of diagnosed coma patients, released him from his torture. Using a state-of-the-art scanning system, Laureys found to his amazement that his brain was functioning almost normally.
My first instinct was to dismiss this. "Radical" and "state-of-the-art" are terms that describe technology that has been essentially unchanged for ten years. Either the old doctors missed it, or Laureys has better technology at his disposal.

Belgian doctors used an internationally-accepted scale to monitor Houben's state over the years. Known as the Glasgow Coma Scale, it requires assessment of the eyes, verbal and motor responses. But they failed to assess him correctly and missed signs that his brain was still functioning.
So there's one answer: they didn't bother to scan him in the first place, or at least update the scans over time. They relied on a behavioral measure.   It happens-- complacency, routine... patient gets offloaded to a nursing home never to be heard from again. It happens.

The moment it was discovered he was not in a vegetative state, said Houben, was like being born again. "I'll never forget the day that they discovered me," he said. "It was my second birth".

And there the science ends, and the politics begin.

II.

What do you want this story to be about?

Many people thought this was a hoax, but not because of what I've described, but because of this:

"I had dreamed myself away... I screamed, but there was nothing to hear," he said, via his keyboard.
Here's a video, but the screen cap tells enough:

That's a therapist's hand guiding his hand along the keyboard. "Facilitated communication" is controversial. Is it Ouija board stuff, or for real? The Amazing Randi and one quasi-famous bioethicist say FC is a fraud. Debate on TV and message boards all focus on FC.

But that's not what the actual news stories are really about. The articles don't even mention Facilitated Communication. And Dr. Laureys doesn't mention it in any of his scientific papers I've read. Even if FC is a hoax, even if this patient isn't really communicating via FC, it doesn't mean he's not conscious. Isn't that really the issue?

That's the hijack: Randi, and Caplan, and the public, can't interpret MRI scans. So instead they'll interpret and argue what they can-- news videos. That's politics.

III.

What does Dr. Laureys want to be true?

I'd like to tell you I looked at the case write-up, but there isn't one. That's very suspicious, but also completely besides the point, because for Laureys, the point isn't about Houben. That's why he didn't even write it up.

What he wrote about, however, was better/newer applications of technology to detect consciousness. We can debate whether fMRIs are really novel or just appropriate practice, but what he is really doing is asking the European governments to pay for it. From Laurey's perspective, he wants to change standard of care to regularly employ this technology.

Following this, it's no wonder the British press keyed in on it.

IV.

What about the Americans?

"We have to re-evaluate cases like Terry Schiavo." Actually, we don't.

For U.S. doctors the application of "high tech" scans is hardly novel, even getting Medicaid/Medicare to pay for it isn't such a struggle. But the comparison to Schiavo's case isn't correct: Terry Schiavo was scanned with an MRI, people just disagreed with what it said. The Houben debate is whether we should be scanning in general.

V.

For my money, the case is suspicious but:

The spectacle is so incredible that even Dr. Laureys had doubts about its authenticity. He decided to put it to the test.
"I showed him objects when I was alone with him in the room and then, later, with his aide, he was able to give the right answers," Professor Laureys said. "It is true."
Laureys would have to be insane to make up a lie of this giganticality, but anything is possible.

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===== ====== ===== The Last Psychiatrist: March 13 Week on Partial Objects
The Adjustment Bureau
All The News That's Fit To Compartmentalize
Physics Envy Can Be Hazardous To Your Health
Amy Bishop Didn't Snap
Simulating The Simulated Experience. With Gum

Looking for others to post their own deconstructions!

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===== ====== ===== The Last Psychiatrist: Marc Maron's Mid-Life Crisis

but the point is to go slower, not faster

Comic Joe Rogan's podcast, The Joe Rogan Experience, this week mentioned a speech by comic Marc Maron.

Marc Maron is a great comic I've referenced before. It's probably not overstepping for me to say he suffers from narcissism, i.e. not that he is a narcissist, but that he suffers its consequences.

Rogan said that when he was first starting out in comedy, Maron (who was already well established) was nice to him and gave him good advice. "I've always tried to be nice back to him because of what he did for me in the early days," said Rogan.

But over the years, as Rogan got more popular and then became the host of Fear Factor, Maron apparently resented him. Maron insulted him whenever he came up; he said Rogan was worse for comedy than Carlos Mencia (the two had a public battle over stolen material), and one night Maron had to introduce Rogan to the stage, and did so with a dispraging diatribe.

Rogan is a savvy student of human nature and a well practiced judge of character; and I'd trust his insight way before any psychologist, let alone the armchair variety they use to stabilize the chairs at The Atlantic. Rogan's point, therefore, wasn't that Maron was a jerk; Rogan still believed Maron was a great comic and a nice guy. The point for Rogan was how some people get caught in a self-hating, self-defeating loop of narcissistic resentment.   Forget about being happy for Rogan's success; or accepting it, or even being jealous of it. Maron took it personally.

For example, from Maron's speech:

I have been doing standup for 25 years. I've put more than half my life into building my clown. That's how I see it. Comics keep getting up on stage and in time the part of them that lives and thrives up there is their clown. My clown was fueled by jealousy and spite for most of my career. I'm the clown who recently read The War for Late Night and thought it was basically about me not being in show business. I'm the clown who thought most of Jon Stewart's success was based on his commitment to a haircut. I'm the clown that thought Louis CK's show Louie should be called Fuck You Marc Maron.

Whether Maron is or is not a narcissist is not the point; this thinking is narcissistic. Anything that happens he relates back to himself, even if it reveals him to be a loser. (Hence the statement: the belief that narcissism is synonymous with grandiosity is itself a narcissistic defense.) So other people's successes don't exist independently, they necessarily provide a commentary, a value, about oneself. His success reflexively implies you're less of a success; his failure reflexively means you're more of a success.

The end result of this thinking is this:

Three years ago my clown was broke, on many levels, and according to my manager at the time un-bookable and without options....I was thinking, "It's over. It's fucking over." Then I thought: "You have no kids, no wife, no career, certainly no plan B. Why not kill yourself?"
By "the result" I don't mean the suicidality, though of course that option is never flatly rejected, it is a last chance at immortality. The result of this loop is the first sentence, the "without options." There are no options not because there are actually no independent options, but because there are no options which change the balance of worth between you and the other person. Because your value is measured relative to the other person, and you've now discovered that you have no control over that other person, you are indeed left "without options." No obvious way to become more successful, OR no obvious way to make Joe Rogan less successful.

II.

I can't tell you how to be successful, but I can tell you how to successfully get through this kind of misery. Note that this advice is not for people in their 20s, it will not work for you, it will only work if you're over 40. (1)

The trick to solving physics problems is to recognize the form of the equation; the trick to solving your life is to know the form of the conflict.

Maron was having a mid-life crisis, which is always of the form: "will I do anything useful with the rest of my life?" Note the emphasized "always." There is no alternative question.

Typically, people misinterpret the mid-life crisis as, "I'm 45 years old and I've never done X" where X equals: blondes; car collecting; skydiving, a book, loved, learned Italian. And while these things are enjoyable, and will bring the person happiness of varying amounts, they don't solve the crisis because the crisis isn't about doing things but about running out of time. "That was fun," you say as she drives back to Wellesley, but then you glance at the calendar and it says you're still 45. There are only two things that will make that 45 less painful, and one of them is alcohol.

All the maneuvers indicative of a mid-life crisis-- younger women, sportscars, new hobbies, new careers, new looks-- are easily interpreted as new beginnings to help you trick yourself that the clock has been rolled back. (That these things do, in fact, make you slightly younger is not here the point.)

So other than alcohol, what answers the question, "Will I do anything useful with the rest of my life?" The key to navigating this stage is to understand that the word "useful" has a very specific definition and can only be fulfilled through limited ways: it has to serve the next generation.

I can see you rolling your eyes. (2) This isn't touchy-feely nonsense; this is how humans were built, no different than they were built to see Roy through Biv or to find the absence of eyeballs uncanny. It explains why happy people still go through this; why making millions of dollars doesn't solve this; why having kids, being celebrated or even famous all fail, not because these are intrinsically "bad" but because they do not specifically fulfill the human necessity to believe it is useful to the next generation.

Most people get through this by raising kids (not just having them), teaching them things, "getting them into college," passing on the culture. The more you feel responsible to this process the easier mid-life will be. Nor does it require active or even good parenting; it is an internal conceptualization of your life, rather than any external activity. Not changing what you do, but how you thinks about it. Though it sounds like a cognitive trick, it is as simple as not saying, "I want to get rich" and instead saying, "I want to get rich so my family has a good life." To emphasize, this is not about the comparative morality of wealth vs. poverty, but the inclusion of the clause "so that" by which the narcissism is dissolved. (Yes, this means one could fool themselves into thinking they are "useful," thus passing through the crisis with not having accomplished anything.)

Maron, however, doesn't have kids. Other options:

1. Become someone's "mentor." You can unload a lot of that rage if you feel valuable, and giving of your wisdom and experience serves the dual function of confirming your identity (I am the guy who..) and connecting with someone else in some meaningful way. (E.g. the ex-player who goes into coaching.) (3)

2. Become everyone's "mentor." This is the route that saved Maron's life.

Broke, defeated and career-less, I started doing a podcast in that very garage where I was planning my own demise... I started to feel better about life, comedy, creativity, community. I started to understand who I was by talking to other comics and sharing it with you. I started to laugh at things again. I was excited to be alive. Doing the podcast and listening to comics was saving my life.

The mistake is to think it is the fame that saved his life. Maron might not be sure what, exactly, he is giving 20 million downloads that is of value, but he knows it must be something, which is why being more famous isn't helping, say, any of the Real Housewives from suicide by collagen injection, but an aging ex-football hero can get a patent extension as a sports commentator. Maybe it's the comedy, or the insight, or the perspective-- what specifically it is doesn't matter, just that he feels as though it is something he is giving others. If Maron had simply been given a check for $20 million dollars to perform one last show and then obligated to disappear, he would have happily taken the money and eventually killed himself, if not with a gun, then with

with internet porn, booze, pills, weed, blow, hookers, hangers on, sad angry girls we can't get out of our room, twitter trolls and broken relationships.

III.

Unrelated, but a great: Louis CK, on the Opie and Anthony show, relates this story:

I'm at the Comedy Cellar, and I make this 9/11 joke. Basically, I was talking about how when you're in a marriage, you always feel like you're doing something wrong, in trouble for something. So the joke is I'm in a hotel, and my wife calls, crying, and I'm thinking, what the fuck did I do now? Did she find a sex phone bill? So I say, "what's wrong?" and she just cries, and finally she says, "turn on the TV" and I see the planes crashing into the towers. And my first thought is, "Yay! Phew! I'm not in trouble, it was just thousands of people getting killed."

So I tell this joke in the Cellar, and some guy just stands up and says, "that, that is not funny," and he stomps out.

Later on I'm upstairs talking to Marc Maron, and I tell him this story, and I'm telling him how much I hate it when people choose their one thing to be offended. All night I'm doing rape jokes and racial jokes and he has no problem, but this is the one thing he decides goes to far. How narcissistic this guy must be to think that he's allowed to decide that what offends him is what should be off limits.

So Marc looks at me and says, "dude, are you insane? He's the narcissist? You just told the most narcissistic joke in history, about how relieved you were that thousands of people died just because it got you off the hook with your wife..."

--------

1. When a 20 year old says, "why is he famous?! For what? I hate that guy?" It's normal. As you get older, you learn accept the unrelatedness of people's successes to your own. "I still hate him, but it's got nothing to do with me." It is a mental disease when a middle aged man reacts with rage to the success of Kim Kardashian, however underserving she may actually be.

2. "I hate these 'solutions' because they aren't really solutions," you say. "It's noble and all, but I need specific advice that can help me." That's the narcissism. You don't want the solution to be "it's about the next generation" because what you want the answer to be is about you-- your own fulfillment, your own happiness, your own safety, your own sanity. All of these are defenses, and none of them will work, viz Marc Maron.

To use an example from The Matrix: The Oracle "lied" to Neo when she said he wasn't the One, but she had to lie in order for Neo to believe that Morpheus was more important than he and to risk his life to save him; only by making this sacrifice, by being willing to exist for someone else, could he actually become the One. Had he "known" he was the One, and then let Morpheus die so that he, the One, could live, then by the atemporal nature of existential logic, he wouldn't have been the One after all.

3. This is how you could help someone else with this kind of "mid-life depression:" making them feel valuable in a consistent way. If this is where, say, your father finds himself-- empty nest or career gone flat-- regularly soliciting his opinion on things he considers himself an expert in can help remind him of his value. The point is not that he needs to accomplish something, the point is that he needs to feel he is valuable to you accomplishing something.

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===== ====== ===== The Last Psychiatrist: Market Capitulation

Gun to head, this is the bottom.

They didn't cut rates, but they did issue new Treasuries because the Fed needs money. And no, there's no inflation, because banks are deflating hard. We may come out of this alive, who knows. (Though for current retirees who had money in "buy and hold" safe financials-- or anything else, for that matter-- well... there's always Social Security. I know, I know, I know.)

They also stopped naked short selling, which is huge. I thought that was already illegal?

For you technical traders:

If we hold 10827, then that's a double bottom and we go to 12500, maybe even 13000. By January. Not sure how that's possible, but there it is.

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===== ====== ===== The Last Psychiatrist: Massacre of The Unicorns

The real problem of a critique of our own cultural models is to ask, when we see a unicorn, if by any chance it is not a rhinoceros.

Massacre of the Unicorns

The real problem of a critique of our own cultural models is to ask, when we see a unicorn, if by any chance it is not a rhinoceros.[i]

It’s a convenient fiction that the difficulties with psychiatric diagnosis and treatment are due to incomplete knowledge- if we just knew more about dopamine!—but the real source of the failings is inherent in its structure. Psychiatry fails because it is designed to fail.

Semiotics and Psychiatry

The problem is with the signs of psychiatry. Signs are vehicles for conveying information. For example, the term “antidepressant” is a sign conveying the idea of a “drug which treats depression.” While tricyclics and SSRIs are both called “antidepressants” because they treat depression, the term otherwise carries no necessary value except that.   Signs can be misused if they are expanded to take on new meaning in an inconsistent fashion.    Consider the controversy over “antidepressant induced mania.” Tricyclics have been shown to be associated with higher manic rates, but SSRIs haven’t. So does that mean that most textbooks and articles are wrong—that antidepessants don’t cause mania? Actually, the problem is worse than that. It’s not that antidepressants don’t cause mania—it is that there cannot be any such notion as antidepressant induced mania.

Hydrochlorothiazide (a diuretic) and propanolol (a beta blocker) are both “antihypertensives,” but otherwise are very different drugs with very different side effects; only one makes you pee.    There’s no such thing as “antihypertensive induced peeing.”

But this error is itself based on an earlier semiotic error, with the sign of “bipolar disorder,” and its implicit idea of two opposing poles.   Depakote will cure and prevent mania; and Zoloft will cure and prevent depression.   The treatment of one pole should surely move the patient closer to the next pole; hence, psychiatrists talk about “antidepressant induced mania” but “Depakote breakthrough mania.”   See the difference? No? That’s because, in reality, there is no difference in the two manias, and absolutely no reason one should believe one is “induced” and the other “breakthrough,” except that the problem has arbitrarily been defined in this manner, i.e. a) mood stabilizers are a priori preventative, and b) Depakote is a mood stabilizer. But a) is a postulate and b) is an optimistic assumption.

A similar example is the often cited myth that diagnosis of bipolar disorder is frequently missed. A survey[ii] found that 69% of patients were actually misdiagnosed, most often as having regular depression. An average of 4 physicians were consulted “prior to receiving the correct diagnosis.” But who is to say what is the correct diagnosis, when the diagnosis is based on vague and overlapping descriptions (and not on objective pathology?) You can look at this the other way, and say only 1 out of 5 psychiatrists felt it was bipolar disorder, while the other 80% thought it was depression. So it pays to have the last word. Bipolar disorder is “frequently missed” not because it exists and doctors miss it, but because it is defined in a way which allows it, by 80% of doctors, to be legitimately called something else. The only way to say the diagnosis was correct or incorrect, in the absence of objective pathology, is to say that the treatment they received for “bipolar disorder” from the fifth doctor was better (read: safer or more efficacious) than the treatment they received from the first four. This is not evident.

Marco Polo's Dilemma

The problem in psychiatry is the problem in the epigraph at the beginning of the paper. When Marco Polo saw the exotic one horned quadruped, his frame of reference required that it could be none other than a unicorn, even though it did not conform exactly to his prior conception of it. Marco Polo made his observation fit his existing paradigm of zoology. While superficially (and in retrospect) this may seem silly and arbitrary, it is in fact the opposite, Marco Polo believed the only thing he could believe—because the alternative was to believe he had discovered an entirely new, unheard of, creature. This is the semiotic problem in psychiatry, wherein we are forced to interpret clinical signs with our available “encyclopedia,” because we lack both the newer encyclopedia, and its accompanying language, to interpret the signs differently. But here’s the extra credit question: is it really a rhinoceros or a unicorn?

Psychiatry is trying to move away from a symptom based field to a disease (or at least disorder) based science. We are deciding (note word choice) that a psychiatric disease exists a priori, and can present with different symptoms, the way cancer could present as the flu, but really is cancer. The diagnosis (or sign) becomes more important than the individual symptoms, because it demands a specific treatment. But if the paradigm is faulty, what of the treatment?

An example is the association of bipolar disorder with mood stabilizer. Through a series of laughable twists, psychiatrists came to believe that antiepileptics had special properties in bipolar because they could quell the chaos in the brain in the same way that they calmed seizure activity there.   It is now common practice, as defined in numerous “Expert” guidelines and consensuses, that patients with bipolar disorder need to be on a mood stabilizer, specifically lithium or the antiepileptic Depakote. The problem with this is that there has never been a study that found that Depakote is a mood stabilizer. In fact, there is no evidence that any antiepileptics are mood stabilizers. What few studies have been done show no benefit over placebo for this purpose. Remarkably, very few psychiatrists know this. But worse, even when you show them data, they refuse to accept it.

I know, it seems—well, crazy—that psychiatrists would blatantly ignore the absence of data—the opposite of data. Ask your psychiatrist the following question: A patient with a history of bipolar disorder presents depressed. There are only two medications available: Prozac or a new antiepileptic for which no efficacy or safety data yet exist. Which do you use? That the mystery antiepileptic is even considered shows the power of the association, because I haven’t actually told you anything about the antiepileptic. Nothing about efficacy, safety, anything. And a doctor would consider it? It’s considered because it is assumed that it will share the same properties as other antiepileptics, i.e. that it is a mood stabilizer. But no other antiepileptics are mood stabilizers, so why the assumption? And even if one seizure drug was, in fact, a mood stabilizer, why would another one be? If antiepileptics have totally different efficacies with respect to seizure treatment, why should it be any different for bipolar treatment?   The power of the paradigm compels us.

Can an antipsychotic be an antidepressant? Sure. Can an antidepressant be an antipsychotic? See? You’re hesitating. It is harder to imagine that an antidepressant can be an antipsychotic—as if there is anything in either term that allows us to predict other actions—because the paradigm has given value to terms that they don’t have.

There’s an analogy in the social sciences: racism.

The Knowledge Trap

But psychiatry is an applied discipline. What’s the harm if assumptions lead to efficacious treatments? This is a trap. Psychiatry has convinced itself that it needs to focus on expanding its knowledge (i.e. data) rather than re-evaluating its postulates and paradigms. New discoveries or information are used to build on a paradigm, not to test it. But now psychiatry is looking to see what it expects to find. And if a discovery flatly contradicts the tradition, then it is ignored or rationalized. How else to explain the comparative absence of articles critically discussing the placebo response? And the even fewer whose proposed solution is not the abandonment of the placebo arm, in favour of “active controls.” Active as defined by whom? Is Depakote an active control?

What Is Modern Psychiatry Seeking?

The fiction is that psychiatry is looking for more efficacious treatments. It is not. It is looking for different treatments; the paradigm does not allow for the creation of better treatments. For example, psychiatry can applaud itself from moving from a “noradrenergic hypothesis” to a “serotonin hypothesis” of depression, but it’s still the same paradigm. While first line medications have changed, they have not changed because of improved efficacy. Nothing has ever found anything to be more efficacious than the previous standard (SSRIs. vs. tricyclics, atypical antipsychotics vs. chlorpromazine, etc.) nor has any “model” been more or less correct than any other. That some medications have less side effects and greater versatility is useful, but a) this is almost never the result of intentional scientific discovery but rather the fortunate by-product of the invention of (yet another) efficacious treatment; b) this greater tolerability in no way reflects the accuracy or inaccuracy of an existing model. That Zoloft is more tolerable than imipramine has nothing to do with the viability of the “serotonin hypothesis.” And yet how many times have I heard that antipsychotics treat depression with no more rigorous explanation than because of their “activity” (note the vague term) on serotonin?

Psychiatry, which seeks to be like physics, becomes instead a caricature of it.   It, too, tries to focus on expanding knowledge and not re-evaluating its principles. But unlike physics, psychiatry has no formal principles. They are made up. It is, strictly speaking, not a science but a paradigm, no different than psychoanalysis. It may seem as though Freud concocted the notion of the unconscious out of thin air and developed an entire field around it, but modern psychiatry has done nothing different in concocting the notions of kindling or “upregulation of receptors” as first principles and then constructing an equally arbitrary field around them. That medications help patients has everything to do with the medications and nothing to do with the incense and liturgy that surround them.

Paradigm shifts do not occur in physics because the principles do not change. Newtonian mechanics will always be useful for prediction because it is correct for the cases in which it is applicable (i.e. for measurable bodies.) It is furthermore not susceptible to political influence. Psychiatry is the opposite. The decision to accept or reject the paradigms in psychiatry are very clearly political, not evidentiary. We as individuals accept the idea that antiepileptics are mood stabilizers because psychiatry has decided to adopt this position, not because the evidence requires us to accept it (in fact, the evidence should require us not to accept it, or at least seriously question it.) No physicist could hope to “practice” physics without having read and understood what came before, without having worked the “block on an incline” problem. But there is no theoretical nor practical requirement to practice psychiatry of reading the papers on, for example, mood stabilization, let alone what came before. All that is required is to know what the current practice is (“Guidelines recommend prescribe antiepileptics.”) This may seem like science, i.e. “scientists have determined that antiepileptics are mood stabilizers, so we will trust their word and prescribe them,” but it is very clearly politics.

The current problem of psychiatry is that it seeks to be something that it is not: science.   It may be, at some future date, readily described by scientific principles, but this is assuredly not the case now.   It is most certainly a sociological construct, a paradigm, with a shared educational system, shared assumptions, and a mechanism to communicate discoveries (i.e. journals, meetings.) It also has a common language. But it lacks the predictive ability common to other disciplines.

An argument against the notion that psychiatry is an arbitrary paradigm is that it is a reflection of what actually occurs in the brain.   This is sophistry. For example, saying the “serotonin system is relevant in mood disorders” is empty because it lacks context. Does it mean that no other system is relevant? Or that it is the most relevant? Or even necessary? Sufficient? What about Wellbutrin? Are you saying psychotherapy alters serotonin? (And not dopamine? Etc)

Why There Can Be No Progress in Biological Psychiatry Using The Current Paradigm

While there is a science of the brain, there is no science of thought. Another way to think of the problem is to question the nominalism of the field. Psychiatry talks about things like mood, emotion, depression. But are those actually real and distinct things? Is there some signal pattern in the brain that is mood that is wholly unrelated to the signal pattern for a thought? Just because something has a name, that does not mean that the thing exists in fact. These may be simply convenient fictions.

To say that because it is known that chemicals can alter what is called mood therefore proves the existence of mood is not satisfactory. The death of a loved one will alter mood as well, often dramatically and to an extreme. How is this possible, if no chemicals are introduced into the system? In fact, nothing new is introduced into the brain except, depending on the paradigm, a) information or b) energy (i.e. converted sound waves.) How does the introduction of a new piece of information trigger an alteration of mood? Why would one thought "My family is dead" trigger the release of some chemicals, but another thought "My family is alive" not trigger that same release? And how does a non-physical entity like a thought trigger a physical reaction? Are thoughts even discrete? Or does the brain operate on a flow of thoughts? Digital or analog?

Linear regression and statistics cannot address all of the problems of chemistry and mood; for one reason because it does not account for thoughts that a patient cannot have while on the drug-- but it is reasonable to think there are some. In other words, if there is some set of thoughts A, a subset B of which are negative and a subset C of which are positive, then is the introduction of a chemical in the brain able to block only subset C, or does it simply block set A? The reverse is potentially applicable: that there are certain thoughts that can be had only when on a drug. (This is obviously evident in the case of perceptions that can be had only on a drug.)

The simple analogy to computer hardware and software illustrates the difficulty in psychiatry. One can understand all of the hardware of a computer system, but this will not explain if or how the computer can run word processing software, video games, instant message or be susceptible to a virus, or make any predictions about the behavior of this software in the real world (for example, no computer technician could predict the writing of this paper, nor, by changing the hardware, alter the content of this paper.)   Hardware is finite, but software is infinite, or as infinite as is thought. Without understanding the mechanism of thought, or at least how thoughts or states can affect mood, then a pharmacology of the brain will simply tread water with no progress towards either treatment or diagnosis. One cannot permanently alter mood without at least simultaneously altering thought. In a sense, there is more logic to the psychological approach, or at least in conjunction with medications, because if software (thought) is the problem, more software is the cure.   While the applicability of “therapy” in schizophrenia may be debatable, there is no reason as yet to decide that any other approach is applicable to mood disorders such as depression or anxiety, and absolutely no evidentiary reason to assume that pharmacology is the superior approach. It is not necessarily faster nor more consistently reliable.

Myths of psychiatry such as those described above are not isolated examples of poor practice or lack of knowledge, but are the unavoidable manifestations of an artificial paradigm which is arbitrarily derived from unproven assumptions, justified by inappropriate logic.   They often lead to ineffective, dangerous, and very expensive treatment. Psychiatry must be more vigilant about its own data.   It is necessary to avoid laziness in our education and understand from where comes our knowledge. There are daily diatribes against the influence of pharmaceutical companies; but the effect of pens and detailing is surely much smaller than the effect of misunderstood data, poorly researched axioms, and signs run amok. Psychiatry will not survive as a medical subspecialty if it continues along this path. It will lose its dignity, and worse, it will become irrelevant.

“It would be good to conclude by recommending a short book, What Is Science?, that does things the right way. It takes a robustly objective view of the relation of evidence to conclusion, explains what laws of nature are, briefly shows how measurement, data, statistics, and mathematical models work in science, states which parts of science are well-established and which not, illustrates with engaging episodes in the history of science, and ends with some colorful rudenesses on postmodernist solecisms concerning science. Unfortunately, it does not exist.”[iii]

[i] Eco, Umberto (1998). Serendipities: Language and lunacy (William Weaver, Trans.). New York, NY: Harvest.

[ii] Hirschfeld RM, Lewis L, Vornik LA.   Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003 Feb;64(2):161-74.

[iii] Franklin, James. Thomas Kuhn’s irrationalism. The New Criterion Vol. 18, No. 10, June 2000

===== ====== ===== The Last Psychiatrist: Why Do The Elderly Commit Suicide?

A thought provoking article. I have to admit this never occurred to me, and that's exactly the problem.

First, a question, and you must commit to an answer: why do the elderly suicide at higher rates? Write in your answer here: _________________________. No, don't read on without answering.

General theory is that they are hopeless, pessimistic, and their intent to die is high. That's what you wrote, right? Me, too.

But what if they died at higher rates not because they wanted to die, but because they were more susceptible to dying, even by a half-hearted, low-lethality attempt?

Using Sri Lanka's most common poisoning, yellow oleander overdose (= cholinergic toxicity), 94/1900 suicde attempters studied died. Elderly were 13 times more likely to die than those under 25-- even when the number of seeds was controlled. And the number of seeds was often low (median was 3). In other words, the elderly were not dying at higher rates because they ingested more seeds; they were dying because they couldn't survive even a few seeds.

Wow. Ok, my previous bias had been to worry most about the intent in the elderly, not so much the means; once they decided to die, they'd find any way they could. Whereas in, say, teens, the bias was to worry about the means, because (often) their intent to die was low, but they might take something that was much more lethal than they thought it would be. A common question I ask is, "which is more lethal, an OD of Zoloft or Tylenol?" Because many believe psych meds are lethal, while Tylenol, an OTC, shouldn't be.

But it may be that I was wrong, and that the elderly have vague attempts just as frequently as others, but actually die from them. Maybe I need to be more careful about prescribing them meds that even in mild overdose could result in their death (Elavil, Tylenol, narcotics, etc)?

What's against this is that 60% of people under 65 use a gun to kill themselves, while 73% of those over 65 use a gun-- suggesting that intent is pretty high after all. But that's not my point here.

What's interesting is why this all never occurred to me. Where did I get the idea that the elderly were more intent on death than the younger people? Certainly, the popular psychiatric literature constantly reminds us the elderly have higher risk; but perhaps a culture which places so much value on youth, and which is incessantly and publicly debating doctor assisted suicide (always for the elderly), the right of family to withdraw care, etc-- maybe all those notions recursively reinforce the premise on which they are based: that old people want to die? Of course a 20 year old doesn't really want to die because he doesn't "understand" death, he has his whole life ahead of him, hasn't learned impulse control, etc. But the old guy "knows" there's nothing to live for...(?)

Yet another reason why doctors should not become social policy analysts. We are too much in the thick of it, and never question our assumptions because we believe them to be axioms.

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===== ====== ===== The Last Psychiatrist: McCain, Obama Describe Tim Russert-- And Themselves

TV journalist Tim Russert, from Meet The Press, died yesterday.

Both Obama and McCain delivered a short speech to the press, around the same time of day, and both did it outside at airports.

They used almost the same words. So what was different?

First, think about what you might say if you were running for office and were asked to say a few words about Tim Russert.

Then, click on their names below to hear them speak their comments, or read the transcript provided:

John McCain:

Senator Lieberman and I would like to make a brief statement concerning the shocking news about the untimely death of a great journalist and a great American, Tim Russert. Tim Russert was at the top of his profession, he was a man of honesty and integrity. He was hard, but he was always fair. We miss him, our thoughts and prayers go out to his family, and we know that Tim Russert leaves a legacy of integrity of the highest level of journalism, and we'll miss him, and we'll miss him a lot. Again, he was hard, he was fair, he was at the top of his profession, he loved his country, he loved the Buffalo Bills, and most of all he loved his family.

Barak Obama:

I've known Tim Russert since I first spoke at the convention in 2004. He's somebody who, over time, I came to consider not only a journalist but a friend. There wasn't a better interviewer in TV, not a more thoughtful analyst of our politics, and he was also one of the finest men I knew. Somebody who cared about America, cared about the issues, cared about family. I am grief-stricken with the loss and my thoughts and prayers go out to his family. And I hope that, even though Tim is irreplaceable, that the standard that he set in his professional life and his family life are standards that we all carry with us in our own lives.

Which one sounded more like you?   Why?

Let's look at it again:

McCain: (125)

Senator Lieberman and I would like to make a brief statement concerning the shocking news about the untimely death of a great journalist and a great American, Tim Russert. Tim Russert was at the top of his profession, he was a man of honesty and integrity. He was hard, but he was always fair. We miss him, our thoughts and prayers go out to his family, and we know that Tim Russert leaves a legacy of integrity of the highest level of journalism, and we'll miss him, and we'll miss him a lot. Again, he was hard, he was fair, he was at the top of his profession, he loved his country, he loved the Buffalo Bills, and most of all he loved his family.

Obama:(118)

I've known Tim Russert since I first spoke at the convention in 2004. He's somebody who, over time, I came to consider not only a journalist but a friend. There wasn't a better interviewer in TV, not a more thoughtful analyst of our politics,   and he was also one of the finest men I knew. Somebody who cared about America, cared about the issues, cared about family. I am grief-stricken with the loss and my thoughts and prayers go out to his family. And I hope that, even though Tim is irreplaceable, that the standard that he set in his professional life and his family life are standards that we all carry with us in our own lives.

Both men used almost the same number of words: McCain 125, Obama 118. The statements were similarly structured (in this order: opener, general description, description of professional life, expression of sadness and "thoughts and prayers," and then legacy.) They were also similar in trigger words, though usually used only once or twice:

America/country: McCain 2, Obama 1
family: McCain 2, Obama 3
profession(al) McCain 2, Obama 1
(Remember, Obama said slightly fewer words.)

One word has an important divergence: the personal pronoun "I." McCain uses it once (0.8% of his words), Obama 6 (5.1%).

You hear it in the style: McCain is telling you about Russert, Obama is telling you what Russert means to him. Note the openings: McCain describes Russert, Obama describes his relationship with him.

Or how both describe his legacy. McCain states it as a fact ("Tim Russert leaves a legacy of integrity") while Obama describes what it means to us ("And I hope that... the standard that he set... are standards that we all carry").

When McCain runs out of things to say at the end, and repeats himself in order to keep talking, what he falls back on is a description of Russert's attributes. Obama begins with a fluent "I" but then searches for words to follow. (For example, "I am...... grief stricken"; "I hope that.... even though Tim is irreplaceable")

There are a number of possible explanations for the disparity in the use of "I", including personal histories with the man (i.e. knowing him well or not knowing him at all), narcissism, context, statement prepared in advance, statement prepared by others, etc. I am not judging either man's character, but if you consider that this is exactly what Presidents do-- as the embodiement of the spirit of America, frame an issue about which they may or may not personally have strong feelings -- then it is interesting to see the differences in the way they will do this.

Discuss.

(And I look forward to your all-caps hate mail.)

-----------

P.S. Similar analysis done on an anti-abortionist's writings.

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===== ====== ===== The Last Psychiatrist: Medical Bankruptcies, Redux
An old post has suddenly received a lot of traffic, and anger. So a clarification.

Here is the original post.

Here is my first comment by way of explanation.

How we argue for something matters, especially when finite resources are at stake.

1. Using bad data, or data misapplied, to support a case weakens the case, especially to those most able to effect change.    I look up the study, I see it's more about disability insurance than healthcare coverage. I think, "is this all the guy has? He had to play a little game to make his case?" If the Harvard guy can't come up with real consequences, it makes me think it's not a real problem.

2. Didn't he just detect a problem (lack of disability insurance) that he has decided to ignore in favor of pushing his agenda?   If he was really interested in the truth, he would want to fix whatever the problem his data showed, in this case, disability insurance. By ignoring the facts of his study and using them to make a different case, it shows he is in support of an agenda-- an agenda which is not likely to fix his reported problem.

Which is fine, we all have agendas, and universal coverage is an admirable one; but it makes his opinion no more informed or useful than an NFL player's. Neither can claim to have any superior insights; Himmelstein probably has superior insights about disability insurance, but he prefers to talk about a different issue.

3. What if the government gave out universal disability insurance? Then these bankruptcies would fall dramatically. Now, by his data, there's one less reason to have universal healthcare.

A salesman doesn't have infinite resources to convince his client to buy. A military doesn't have unlimited resources to fight every battle in the world. Lawyers do not have unlimited resources to defend a client, and these are all public goods in the same general range of importance as healthcare. (NB: not all healthcare is life-saving.)

---
see also

50% of Americans receive food stamps

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===== ====== ===== The Last Psychiatrist: Mel Gibson Audio Tapes: A Closer Look At What Was Said

ain't we a pair, raggedy man

The purpose is not to criticize either one or to place blame; the purpose is to prevent this from happening to you.

(transcript from Salon.com, with corrections made by me listening to the tapes on Radaronline.)

Tape 1:

===== ====== ===== The Last Psychiatrist: Merck Publishes A Fake Journal
Oh, The Last Psychiatrist wrote another conspiracy article. That must mean it's wrong. So I don't have to deal with it. Phew. Pass me the Blue Pill, I'm feeling anxious again, for no reason at all.

From The Scientist:

Merck paid an undisclosed sum to Elsevier to produce several volumes of a publication that had the look of a peer-reviewed medical journal, but contained only reprinted or summarized articles--most of which presented data favorable to Merck products--that appeared to act solely as marketing tools with no disclosure of company sponsorship.
The journal is called the Australasian Journal of Bone and Joint Medicine. No, I'm not kidding.

Cue populist rage: "Pharma is tricking people! There needs to be a separation between Pharma and medicine!   Don't let them in our medical schools to corrupt our impressionable 30 year old students!"

Go to bed satisfied; no sex necessary.

I.

I have a question: is anyone accusing Merck of faking the data? Are the studies all lies? No. This journal contained research previously published (and I assume therefore peer reviewed) elsewhere, and review articles. I'll grant that the review articles are hardly cutting edge, but no one can say they are false or incorrect. Isn't it possible that Merck might have something useful to say on the subject of bone loss?

"But they're misleading, in that you don't know Merck is sponsoring them." I see. So what you object to, actually, is not the content, but the impression. What matters to you are appearances.

II.

Any doctor who couldn't sense something is amiss with a journal called "Australasian" anything is an idiot. And a danger to the public. He is much better off doing exactly what Merck tells him to, and not thinking for himself. I'm absolutely serious. Do you really think such a doctor is in any position to critique the methodology of a clinical trial? Make reasonable distinctions between treatments? Of course not. You know what he'll do instead, as a shortcut? Look for the financial disclosure.

III.

"I've seen no shortage of creativity emanating from the marketing departments of drug companies," Peter Lurie, deputy director of the public health research group at the consumer advocacy nonprofit Public Citizen, said, after reviewing two issues of the publication obtained by The Scientist. "But even for someone as jaded as me, this is a new wrinkle."
New? Hey Ponce De Leon, what did you think the past fifteen years of throwaway journals were?

III.

All together now: What does the author of this story want to be true?

The point of this story is to direct your outrage onto Merck publishing a biased journal, so that you are not conscious of the fact that all of the journals are even more biased.

I can, and have, published an entire journal by going to Kinko's at 3am, and I did it drunk. And it was in physics. So why would Merck need to partner with Elsevier to get a limited run of a fake journal? Obviously it is because having the Elsevier imprint makes the journal appear more legitimate. Fine.

So why would Elsevier partner with Merck? You think it needs the money? Elsevier can get the money for the journal this way, or it can get it from selling ad space, or it can get it via the study authors who are funded by Merck ("publication costs.") It's the same money. What's the difference to them? Why do it this way?

Here's why: by publishing a fake journal, it can then apologize for making a fake journal, thereby reinforcing that its other journals are not fake: "sorry, this does not meet our otherwise high standards of integrity."

IV.

Oh, the other journals aren't fake? Then, knowing nothing about osteoporosis and without looking, I shouldn't be able to tell you that all the articles about Fosamax published in the past year will say it's good; except for any published in NEJM, which will say it's bad. Wow, what do you know, I was right. (NEJM: 1 2 3 4)

Of course I don't want Merck publishing journals. But they have been publishing the content of all the other journals for decades. They control you practice, and you don't even know it, because you think, "I've never received anything from Pharma!" Yes you have, you received their message. Or did you prescribe Vioxx (and Depakote and blah blah) because you analyzed the data and you thought it was better/safer than the alternatives?

You think there's any difference at all to the patient between getting paid to prescribe Fosamax, and prescribing it in good faith based on hearing about the studies conducted by academics who were paid by Merck, reviewed by three other idiots/academics also paid by Merck, and published in a journal with ads paid by Merck; and while medical students are taught in school that Fosamax is useful for X and Y, based on those journal articles?

Do you think the elderly are on 8 meds at a time because they're all necessary?

And at least I have a good idea of the bias Merck has on Fosamax, I know how to interpret their results. Do you think I have any clue what to do with anything published in NEJM? Do you think a layman has any chance when the regular media reports, "scientists have found that..."

You're worried about Australasia?

The question isn't whether Merck should be able to publish a journal; the question is why no one is rioting.

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===== ====== ===== The Last Psychiatrist: Merry Christmas

8,000 Americans dead in 9/11, Iraq and Afghanistan.

Don't email me with your "but what about" and "how can you equate--" It's a fact, not a moral reckoning.

Every one of them is missed by someone.

Every one of them leaves behind a half-person, or perhaps twice a person, as they have to both eat pizza and open presents and smile at work while also carrying the burden of pointless emptiness.

You hear his voice in a park, see him just rounding a corner. And every morning before you open your eyes you try to wake yourself up back--

But time goes only in one direction. Better than spiraling inwards, towards nothing, as it does for parents who are left marking time after their child has moved on.

There's no shame in making him a memory and moving on, but there's not much relief in it either.

Hail and farewell.

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===== ====== ===== The Last Psychiatrist: Michael Jackson Died Of Overdose
But the question is, an overdose of what?

According to CNN, this is the timeline of drugs he received on the day he died:

1:30 am.: 10 mg Valium

2 am: 2 mg IV Ativan

3 am: 2 mg IV Versed.

5 am: 2 mg of IV Ativan.

7:30 am: 2 mg of Versed; placed on pulse ox (measures amount of oxygen in blood-- used in these cases when you worry they may be too sedated to breathe)

10:40 am: "after repeated demands/requests from Jackson," Dr. Murray administered 25 mg of propofol.

I.

We can say that this is enough drugs to kill a horse, but look at 5am: Jackson is still awake. And at 7:30. And at 10:40. It may seem like a lot of drugs to you, but regardless, they were too weak to put him down. Therefore, you can't say these were lethal levels of medications; half a bottle of rum is lethal to some people.

So when CNN does that idiotic segment where they give a reporter propofol to show how strong it is, you should take that for what it is: pornography.

II.

Farily safe to assume: this isn't the first time Jackson's taken these drugs, at these doses.

III.

It's extremely unusual for a doctor to be charged criminally in such cases, unless there was malice; they are usually dealt with in civil court (malpractice) and/or by a medical review board.

It is going to be impossible for a prosecutors to prove, beyond a reasonable doubt, that Dr. Murray killed Jackson.

First, the amount of drugs Murray administered was not only not lethal-- it wasn't even effective. Jackson was wide awake, all night.
That amount of benzodiazepine drugs is not at all unusual for a benzo addict. If Jackson was used to that amount, it's going to be very hard to show why that amount, on that day, killed him.
Which brings us to the second point: we have no way of knowing whether Jackson was giving himself extra oral, or even IV doses of the same drugs, that Murray didn't know about.   Apparently, Jackson had 8 other bottles of propofol in the house, along with other Ativans, etc. It wouldn't be surprising if Jackosn was taking extra Valiums throughout the night.
Third: "What about the propofol? The coroner said high blood levels of propofol killed him." If the coroner said this, he is a fool. Picking out one drug as the cause of death is like blaming one section of the ocean water for a drowning.   The effect of propofol only lasts 5-10 minutes. If it was a single injection, it would have stopped working after that long. Propofol rarely accumulates to high blood levels because it clears so quickly; a high level would suggest either supplementation, or Murray was lying. Then the prosecution's case falls apart: either Murray told the truth about the 25mg, and therefore Jackson was supplementing; or he was lying, which... good luck proving that.
Unless Dr. Murray gave him a propofol drip and forgot to turn it off. That would be...
In any event, unless you give a high dose all at once, in order to die you would have to maintain the propofol infusion, i.e. not turn it off. That wouldn't be negligence, that would be retardation or murder.   But that would be the only way propofol could have killed him.
Fourth: administering propofol along with benzodiazepines is not unheard of, nor is using it outside a hospital with nothing more than a pulse ox. (e.g. used commonly in a doctor's office for a colonoscopy.)

IV. There is one way this could be an easy case of negligent homicide: if Dr. Murray administered the propofol but, contrary to what Dr. Murray said, he didn't have any monitoring equipment. This is the part of the story that makes no sense to me. A pulseox is a simple machine to measure blood oxygen levels, you clip it on the patient's finger and watch the readout display numbers from 0-100%

In order to die, you must first fall asleep, and then your breathing slows and stops. This takes minutes, not seconds. Wasn't it on after Jackson fell asleep? If so, why didn't Murray hear the first alarm that goes off when the oxygenation fell below a certain, non lethal level? Did he have it off?

It seems crazy to me that you would have a pulseox, put it on the patient, but ignore the readout for the crucial hour after the guy falls alseep? Especially after all those benzos?

Of course, having a pulse ox to detect low oxygenation is pointless if you don't have supplemental oxygen on hand.

The simple explanation is that he either didn't use the pulse ox (negligence) or he did use it but paid it no mind (negligence and stupidity); or he did use it, heard the alarm but was unable to save Jackson despite his attempts. This is all assuming he did give only a single injection of propofol, not a propofol drip.

Murray says he did administer CPR and flumazenil (the antidote for benzos, but not propofol) but the timeline is hazy. Maybe Murray was scared of getting in trouble, so he lied about the times; but if he did use the pulse ox and diligently tried to save him, then there's really no criminal case here.

V.

A small clinical aside, I neither expect Dr. Murray to know this, or even the majority of the doctors. There's a difference between time of onset and peak blood level. Just because the pill doesn't work in 30 minutes, doesn't mean there isn't another 70% of the pill coming in an hour.

This is how famous people die: they take stimulants to party all night, and sleep very little. Finally, on day 3 they're too wired to fall asleep naturally, so they take a few extra sedatives (because they feel so wired.) However, the full dose of the pills doesn't happen until after they fall asleep; the sedation is worsened even further by stimulant withdrawal; and, of course, the natural exhaustion that comes with partying for three days and not sleeping.

Smaller doses, more time. That's the secret to not being ruled a suicide.

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===== ====== ===== The Last Psychiatrist: Miners Get Paid, As Expected

real American heroes

Are they tough? Damn straight. Are they heroes? No way, Jose.

COPIAPO, Chile - The first three rescued Chilean miners out of the hospital celebrated their new lives as national heroes Friday, as word emerged that the 33 want to closely guard their story so they can fairly divide the spoils of their overnight media stardom.

There's a subtlety to this story that might have been missed: they were already anticipating big paydays while they were still in the hole.

If society wants to pay them for the human interest story; if there's a market for that, I certainly won't stand in their way, but don't ask me to participate in the alteration of reality that these guys are heroes. Put me in a hole for 69 days with no hope of rescue-- call me a hero. Put me in a hole for 69 days with no hope of rescue but every probability of a big pay day, and this stops being heroism and starts being a reality show.

"This is not a reality TV show," he said.

He's half right-- it's not reality, it's meta reality: pretend to be miners trapped in a hole. Pretend not to be miners trapped in a hole about to get paid.

Ramirez, as you'd expect from a man who embraces the risks of his profession [mining], scoffed at the need for all the psychological treatment.
"When we first spoke to the miners down below ... they weren't in bad shape," he said. "Psychologically, they weren't in bad shape at all."
But being thrust from the dark chambers of a gold mine into the limelight -- and knowing how to cope with overnight fame -- is quite another matter.

Note that the last sentence appears in the form of a reversal: that's narrative construction to keep you interested in a story, but it is factually inaccurate. They weren't psychologically tough and now have to deal with overnight fame; they were psychologically tough because they were anticipating overnight fame. Which isn't to say that they wouldn't have survived even if there was no money-- who knows?

So now they're going to make a TV show about them? I'd like someone to explain to me how a movie about their ordeal differs from the news coverage of their ordeal, except that it is temporally contiguous. Did the news not capture the drama? Did the news not sex it up?

The real mind bender for the media is: how do you tell the story about heroism, when the "heroism" exists precisely because of the story?

II.

God told Abraham to take his only son, Isaac, to Moriah and sacrifice him. The popular telling of the story is that this was a test of Abraham's faith. Abraham obeyed God; but at the moment he was about to plunge the knife into Isaac's heart, God called to him and stopped him

for now I know that you fear God, seeing you have not withheld your son, your only son, from Me.

Abraham passed the test! Yay!

But what did he really do? If God tells you to do something, there's no issue. He's the highest law, so you obey. Abraham's actions-- murder-- would neither be wrong (God is the highest law, he decides what's right and wrong) nor heroic: I did this because God said to. All Abraham did was exhibit a preference for God over his son. In the logic of the Bible, is that such a big deal?

St. Paul adds:

By faith Abraham, when God tested him, offered Isaac as a sacrifice. He who had received the promises was about to sacrifice his one and only son... Abraham reasoned that God could raise the dead, and figuratively speaking, he did receive Isaac back from death.
Abraham had in the back of his mind that God could even raise Isaac from the dead. So what's the worry? And, despite God's insistence that Isaac was his only son, he had a backup in the woods somewhere. Just call him Ishmael.

This is a painting of Abraham leading Isaac to sacrifice in what I assume is colonial Williamsburg. Domenichino thought it important enough to paint three palm trees, but you know what he didn't paint? God. Because he's not there.

Could Abraham actually hear God? Of course not-- so he could only assume that what he thinks he heard was God telling him to kill Isaac. Otherwise he was insane. If he heard God, there's no test of faith, only a test of preference-- God or Isaac. But not hearing God, he had to both prefer God and believe he had heard Him.

If Abraham had actually killed Isaac, then Abraham would actually be a murderer, punishable by whatever they did back then. And he would know that, but he would have to kill Isaac anyway.

But neither was belief in God enough. He had to believe in God and simultaneously have faith that such a God would not allow Isaac to die. "I believe God wants me to do this, but I have faith that this kind of God would not allow me to do something wrong, and no, even I'm not sure about any of this." The real test God was challenging him with was, "do you believe in the right kind of Me?"

"All of this is absurd." That's why he's anxious. But the question is, what's Isaac to make of all this?

III.

Bible study is over. Now to NYC, where the city has paid about $1B since 2000 in settlements for claims against the NYPD.

"Right now it's open season against the city. Just file a lawsuit, and you're going to get money," said City Council member Peter Vallone, who has sponsored a bill he hopes will make it impossible to pay out dubious claims.

I realize many are legitimate, their legitimacy is not my concern.   "Some multimillion-dollar settlements have gone to officers themselves for on-the-job injuries." Fine.

NY public hospital claims were almost $3B.

There's a shortage of money but a plethora of lottery tickets, and you can't fault a person for playing the numbers. There are too many other people in the world, sufficiently odd looking to be slightly unreal, and so only a tiny, tiny amount of the world's attention, help, concern, love, is directed at you. Hell, your own wife doesn't like you that much. So if a transit bus happily breaks your leg, there's no shame in taking a 100 grand with you into your isolation.

But there's no honor in it, either.

The money, the narcissism, makes even good men go the wrong way. Why not me? Why not get paid for my suffering? And the answer is: there is no reason, you earned it. I guess.

But don't call it heroism. Have the dignity to hide it from everyone, you may have earned that money but you did not deserve it. It is not a mark of distinction, any more than sleeping with your sister-in-law.

A real hero would come out of that hole, take one look at the nonsense around him, and say, "Fuck you. Fuck you and your cameras. I'm getting a sandwich."   That would be a show of inner strength, people would wonder "how did he do it? how could he survive? how could he not make a statement?" and they would be infuriated by their inability to tie it to something outside, to tie it to their own shame.

But they very preposterousness, the impossibility of even conceiving this kind of response shows that if we were Abraham, Isaac would be dead.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Missing The Point At The NY Times

This time by one of our own (academic psychologist, Harvard) in an Op-Ed, entitled, "I'm Ok, You're Biased."

The premise is summarized here:
Doctors scoff at the notion that gifts from a pharmaceutical company could motivate them to prescribe that company's drugs, and Supreme Court justices are confident that their legal opinions are not influenced by their financial stake in a defendant's business, or by their child's employment at a petitioner's firm. Vice President Dick Cheney is famously contemptuous of those who suggest that his former company received special consideration for government contracts.

Which would be an ok, if not tired, set up, except for the very next sentence:
Voters, citizens, patients and taxpayers can barely keep a straight face.
It's the populism of the message that is laughable. So doctors, lawyers, Supreme Court Justices and others have no idea that they're biased, but the average joe does? Seems pretty unlikely. But-- maybe they are biased and it's okay.
And the proposed solution, of course, is the same knee jerk ineffectual nonsense proposed before:
In short, doctors, judges, consultants and vice presidents strive for truth more often than we realize, and miss that mark more often than they realize. Because the brain cannot see itself fooling itself, the only reliable method for avoiding bias is to avoid the situations that produce it.

There's that determinism so popular among those who feel powerless.
I hope that the irony of the NY Times, through a psychologist, preaching about objectivity is not lost on anyone. It is so bad at that paper that both the right and the left simultaneously blast it for overt bias. No wonder that the NY Times stock has lost 50% of its value in two years.
Why not discuss the bias of journalists? Or, more importantly, why are they assumed immune from it? This isn't an idle political question, it is the very essence of this debate.
I'll state it explicitly: first, the reason it doesn't matter if doctors are biased (and why it matters very much if journalists are) is because medicine is supposed to be a science. If it is a science-- receptors and all-- then it shouldn't matter what I think, it should matter what is true. I can delude myself and say that seizure drugs are mood stabilizers for the long term; but that doesn't make it true. But if you want to actually see if it is true, you have to look it up. And don't come back with "one negative study doesn't disprove its efficacy." This is science again: it's not up to me to disprove its efficacy, it's up to you to prove it has any.
So the real question isn't bias, it's whether medicine in general is paying attention to its own data. Do we read our own studies, or hope the "thought leaders" will, and then write us a synopsis? Do we believe it because Harvard said so? Is this science, or a cult of personality?

Second, when discussing medicine, the question of bias is not the important one. Yyou have to ask what the harm is. Thie bias isn't harmful to science because science should be able to stand on its own. The bias is only harmful to patients-- so the real question we should be asking is not if there is bias, but if it harms patients. Ready: pretend a family doc gets paid $800,000 by Pfizer to prescribe only Lipitor, no Zocor, Mevacor, etc. What, exactly, is the harm? It's not snake oil: in all the anti-pharma controversy, no one is accusing them of selling a product that doesn't do what they say it does. So unless you can tell me which patient shouldn't get Lipitor, but should get Zocor, then you can't argue this hurts the patient. I'm not saying it isn't sneaky, or unethical. But unless you can show the harm, you can't say it's harmful. That's what's relevant.

But we're not really worried about patients, are we? That's a screen. What this is all about is our own impotence; anger against people who are perceived to have power. We don't even actually believe our own nonsense. This is the same argument against Vice President Cheney. If everyone is so sure that the Iraq war was about oil and Halliburton, why didn't everyone buy Exxon and Halliburton stock back in 2002? It's fun to criticise, I know. But belief without follow through is pointless. If you're not willing to act on your own beliefs, why should anyone else even listen to your crazy beliefs?

I'm not saying doctors and politicians aren't biased. I'm saying we should worry about the things that actually matter. Want to start somewhere, Daniel Gilbert? Academic medicine, and the journals that are their propaganda arms. These people aren't scientists, they are science journalists. And they are very much biased. Don't believe me? Call me when you look up everyone's supporting references.

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===== ====== ===== The Last Psychiatrist: MMR Vaccine Finally Cleared Of Assault
Listen carefully, medicos. It's the sound of your approaching irrelevance.

"Officials Say 'Bad Science' Links Vaccines, Autism"

Officials with the U.S. Court of Claims said they sympathized with the families, but there was little if any evidence to support claims of a vaccine-autism link.

The evidence "is weak, contradictory and unpersuasive," concluded Special Master Denise Vowell. "Sadly, the petitioners in this litigation have been the victims of bad science conducted to support litigation rather than to advance medical and scientific understanding" of autism.
etc. Now that this is behind us, it's okay to ask why it took a court to examine the evidence for the link, even when the evidence was known to be fabricated.   At what point in a civilization's demise are the doctors so uninterested in their own work that they turn to lawyers to tell them what's what?
"But the doctors already knew, it was the public." Oh, ok, I'll rephrase: at what point in a civilization's demise are doctors so uninterested in their work of informing the public of what is healthy and what is not, that they leave it to lawyers to decide and journalists to disseminate?
Lawyers for the families said they were disappointed.
No doubt.
"I must decide this case not on sentiment but by analyzing the evidence," said Special Master George Hastings Jr.
"Unfortunately, the [parents of the autistic child who blame the vaccine] have been misled by physicians who are guilty, in my view, of gross medical misjudgment," Hastings concluded.
Wait, what? Decide not on sentiment? You mean you can make reasoned judgments without knowing who got paid how much? You mean doctors can make serious conceptual errors that aren't the result of financial influence?
The hell you say, sir. The hell you say.

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===== ====== ===== The Last Psychiatrist: MMS Chicks: Oil, Sex, Drugs And Anything Else You Want To Imagine

This is the article I got on my RSS filter that uses the keywords, "things I wish I did in college."

I. " Culture Of Substance Abuse and Promiscuity." Awesome!!

A brief summary of one of the most popular stories of the week:

Government brokers responsible for collecting billions of dollars in federal oil royalties operated in a "culture of substance abuse and promiscuity" that included having sex with energy company employees, accepting lavish gifts and rigging contracts to favored firms.

Wow, just like drug reps. The Denver Minerals Management Service, part of the Department of the Interior, manages royalties received from oil companies who drill on federal lands. It employs super hot women who know what they want and know how to get it.

Here's the paragraph that launched a million erections:

"During the course of our investigation, we learned that some RIK employees frequently consumed alcohol at industry functions, had used cocaine and marijuana, and had sexual relationships with oil and gas company representatives," the report said. Two government employees who had to spend the night after a daytime industry function because they were too intoxicated to drive home were commonly referred to by energy traders as the "MMS Chicks."

The article also quotes an email from a Shell employee to a sexy MMS employee about a tailgate party:

"You're invited... have you and the girls meet at my place at 6am for bubble baths and final prep. Just kidding..."
Ooh. I'll bet he's not!

One worker admitted having a one-night-stand with a Shell employee. That same individual allegedly passed out business cards for her sex toy business, Passion Parties Inc., at work, and bragged that her income from that business exceeded her salary at the Interior Department.
The word "sex" is in every one of the first five paragraphs of this story, except one-- in which appears the words, "fraternity house atmosphere."

You get the idea.

Actually, you don't.

II. Wait, that wasn't my news filter's keywords, it was the media's news filter's keywords

Yes, it's an easy target. Do you know how many articles and blogs make the joke, "Oil For Sex" or "I want a job at the MMS!" And a quintillion innuendos employing "drill drill drill," "what the President wants-- more Bush!" or a picture of a pumping oil rig. Isn't that hilarious? Right out of the Ray Romano Guide To Hack Comedy.

Ok, you get the idea, the deconstruction is obvious. The story is sexy, it appeals to a news media obsessed with ratings who in turn need to pander to a population too jaded for porn, etc, etc. It doesn't mean these people weren't unethical, but it suggests that the media focuses on things that are titillating.

You get the idea.

Actually, you don't.

III. The MMS Chicks

Despite the level of detail contained in the article, the thing they didn't include-- and when I say it, you're going to suddenly nod your head in understanding-- was a photo of the MMS Chicks.

Consider that within seconds of the decision to expose Eliot Spitzer, the media had the name of the prostitute, an awesome picture of her in a bikini, her MySpace page, etc-- all this, depsite the fact that she was using an alias.

But here, nothing.

Lest you think this is because they couldn't identify them, half of the entire Dept. of the Interior report-- where the media got all of its information-- is devoted to these women. (No mention in the article of the other 7 people in the report.)

So it struck me as unusual that the media did not try to publish their photos, let alone their names. When was the last time the media reported on a sexy story and didn't show you the most outrageous, sexualized, unclothed pictures of the women? Every picture of Monica Lewinsky was of her gigantic mouth. (Even poor JonBenet always appears in her beauty pageant attire. You think they couldn't find another picture of her?)

So where the hell are my photos of nubile ex-college cheerleaders who now work in Ann Taylor suits, but get photographed in bikinis?

Oh...

IV. America Hates The Red Pill

And it becomes more apparent that the article isn't about a government office wasting taxpayer funds-- the actual story-- but a loosely based historical fiction about sex.

For example, go back and read the first quoted paragraph-- two women, sex with oil company employees, cocaine and alcohol, sleeping over because they were so drunk...

Awesome story, except: these things didn't all happen at the same time.

Yes, two women got drunk and had to stay over at a condo paid for by Shell. Yes, one woman smoked marijuana at home-- never at work-- and the other used cocaine (last in 2005) (also not at work.) And yes, they had one night stands with oil company employees, though to be clear, neither was having sex with them to influence business-- the men were not involved in the contracts.

But it's not sexy that way. It's sexy only when you put them all together. And if photos get in the way of the fantasy, please leave them out.

V. I Said America Hates The Red Pill

Let me be explicit: the media doesn't focus on sexy stories because that's what the public wants to hear; it constructs sexy stories because that's what it thinks the public wants to hear.

Or maybe it's simply random that Reuters decided to use this photo to accompany the story:

See? They've been sent by the oil companies to get drilled.

Interestingly, while no one published a picture of the women, everyone published pictures of the overweight middle aged man at MMS who was up to nonsense. Because his picture is perfect for the fantasy story: a midde aged man gets to bone his hot secretary.

Unclick your caps lock before you send me your insane emails saying, "how can you justify what they did!" and "maybe they focused on the sexy parts, but it's unethical just the same!" I'm not saying what went on wasn't unethical, I am saying that there is nothing, absolutely nothing, in the news stories that allows me to accurately judge what went on there. There are facts, sure, but they are cut and paste facts, they are Mad Libs, the point of the story is a not information, it is fantasy, entertainment. They carefully choose how and what to tell you in order to create in you an unconscious image of oh, I don't know, those two girls above drunk and naked in a ski lodge with oil company executives squirting them with champagne.

I can no more judge the facts of this story with these articles than I can make any claims to knowledge about either schizophrenia or John Nash from A Beautiful Mind.

This isn't the media's "liberal bias." Hell, it would be fine if they actually had a liberal bias, so I could tell what side they were on. They only have a sensationalist bias.

I'll say it again in case you're still on GMail: the media doesn't focus on sexy stories because that's what we want. It creates stories that are not real, like movies "based on a true story," because that's what we want. The New York Times has become Amazing Stories.

VI. But Why Not Just Look At Porn?

Because that's not what we want.

You're not asking the media to give you a sexy story, you're asking for a sexy story.

15 years ago I was nearly certain that the availability of online porn would destroy a generation of teenage boys. Didn't happen, at all. It's quickly apparent teenagers aren't that interested in porn. Two seconds on the Google Pornotron reveals that currently the biggest thing in porn is MILF porn. What, you think a nation of teenagers wants to bone middle aged women? Dream on, sailor. If you're watching it, it's for you.

This is out of the Michael/Michel Foucault playbook. A focus on the taxonomy of sex, to disclose every detail, how and when and where and what, on the one hand pretending it should be secret and private, on the other hand publicly judging every kind of it. The more you talk about it, the more it can be controlled. The real power is in the discourse, analyzing every aspect of everyone's behaviors.

Control the sex, and it gets internalized: now you know what is normal. And normal can be loosely defined as the Panopticon of Sex: what would you not want to get caught doing?

Foucault said the discourse was for power, control. Sure, but it can also be used to gain access to what is titillating. You want a way to talk about what you would not want to get caught doing.

"Why don't you just look at porn?" Because mostly it's too unrealistic-- it could never happen, and it leaves nothing to the imagination. What we want, what we really, really want, really want, is what we had in college: some guy telling you what he heard this one sorority girl did.   That's sexy. But updated for our current lives.    We don't want stories of sorority girls, we want stories of sorority girls who grew up into MMS chicks. And if that story did not really happen, please make it sound like it happened.

And the news media provides us with exactly what we want, our posturing about the banality of it all notwithstanding. Reality is too boring, and world events too complex, too overwhelming, and, frankly, too not about me. We want entertainment, diversions, that look enough like social policy analysis that we don't feel too guilty discussing them ad nauseum. We want masturbation that looks like work.

Pay attention: you're not asking the media to give you a sexy story, you're asking for a sexy story.

Story. That's all.

(For more like this, see the old Katy Perry story. And if you are so inclined, please Digg/reddit this post.)

===== ====== ===== The Last Psychiatrist: Modafinil vs. Clozaril

I'm researching modafinil for my last post, and bam-- I see this thing. How is no one talking about this article? Does no one read anymore?

A short intro to EEGs and antipsychotics.

Generally, antipsychotics increase power across all frequencies, but each drug (or receptor system) is associated with a specific frequency's power increase. Additionally, antipsychotics' effects are region specific: here, the prefrontal cortex gets the majority of the effect.

Effects of haloperidol 0.5 mg kg^-1 s.c. (A) and 1 mg kg^-1 s.c. (B); chlorpromazine 0.5 mg kg^-1 i.p. (C) and quetiapine 2.5 mg kg^-1 s.c. (D) on EEG spectral power in rats. Panels on the left show data from prefrontal cortex, panels on the right show data from sensorimotor cortex.

Everything is higher (i.e. above the line), but see how each drug or dose changes which frequency sees the most increase in power? So now you can make a comparison table:

Summarizing:

D2 blockers (haldol, racloperide): increase in 10-15Hz power band (lesser in 15-20Hz)
Pure 5HT2A blockers (MDL100907): increases 2 Hz power band
High 5HT2/D2 ratios (Risperdal, sertindole): peak synchronization at 7-10 Hz.

In other words, mixing receptors gets you a mixed effect on EEG.

Additionally, drugs with high alpha-1 blockade (Clozapine, chlorpromazine, quetiapine) increase in 8-10 Hz power band.

You would guess that mixing an antipsychotic with apomorphine (a dopamine agonist) might decrease these effects, and mostly this would be right. There seems to be more effect on the sensorimotor cortex, but this isn't today's message.

What do you think would happen if you mixed Provigil and racloperide (D2 blocker) or clozapine? With racloperide, Provigil increased the power in the 10Hz band in both prefrontal and sensorimotor cortex-- a lot.

But apomorphine added to clozapine had no effect-- and Provigil added to clozapine decreased-- and at high doses almost totally extinguished-- the effect. This is the opposite of what happens in a pure D2 blocker!

Effects of the co-administration of clozapine (CLZ, A) 0.2 mg kg^-1 s.c. and modafinil (MOD) 62.5 mg kg^-1 i.p. (B), 125 mg kg^-1 i.p. (C) or 250 mg kg^-1 i.p. (D) in rats. The ordinate represents the percentage change in EEG power. Vertical bars for each Hz show 95% confidence intervals. Panels on the left show data from prefrontal cortex, panels on the right show data from sensorimotor cortex.

The likely explanation is alpha-1 blockade. Clozapine is a potent alpha-1 blocker. The wakefulness promoting, and EEG, effects of Provigil, which has no affinity for adrenergic receptors, are strangely blocked by prazosin (an alpha-1 blocker.) Thus, the specific effects of clozapine on EEG synchronization must be through alpha-1, not dopamine (i.e. the opposite of racloperide), as evidenced by the fact that they can be negated by Provigil, but not by apomorphine (again, the opposite of racloperide.)

In other words, alpha-1 blockade is integral, not incidental, to the antipsychotic efficacy of clozaril. It's not just orthostasis. This bodes well for Seroquel as well. But the reason why alpha-1 blockade is important is not clear. More on this when I figure it out.

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===== ====== ===== The Last Psychiatrist: Mood Stabilizer + Antipsychotic for Bipolar

This slide-, taken from a drug company program- like many others-- shows that using a mood stabilizer + antipsychotic is better than mood stabilizer alone.
Look carefully. This is what is wrong with psychiatry.

As you can see, Risperdal + Depakote (orange) is better than Depakote alone (blue.)
This is not a finding unique to Risperdal. Every antipsychotic has virtually identical data for adjunctive treatment, which is good, because they shouldn't have different efficacies.
So given that 8 other drugs have identical findings, these data suggest that, essentially, two drugs are better than one.

That's obvious, right? That's what the picture shows?   Well, here's what's wrong with psychiatry: without looking at the slide, tell me what the y-axis was. Write it here:______________
The problem in psychiatry is that no one ever looks at the y-axis. We assume that the y-axis is a good one, that whatever measure used is worthwhile.   We assume that the y-axis has been vetted: by the authors of the study, by the reviewers of the article, by the editors of the journal, and by at least some of the readers. So we focus instead on statistical significance, study design, etc. Well, I'm here to tell you: don't trust that anyone has vetted at anything.
The y-axis here is "% of patients with a YMRS <12." What's a YMRS? A mania scale. But what is a 12? Is it high? Low? What's the maximum score? What counts as manic? What questions does the YMRS ask, how does it measure the answers? You don't know? Again-- we figure someone else vetted it. The YMRS is a good scale because that's what scale we use.
Forget about the YMRS-- what does "% of patients" mean? If this is an efficacy in adjunct treatment study, why not have the y-axis be just the YMRS, to show how much it went down with one or two drugs?
Because that's the trick. This y-axis doesn't say "people got more better on two drugs."   It says, "more people on two drugs got better."
Pretend you have a room with 100 manics. You give them all Depakote, and 30% get better. Now add Risperdal-- another 30% get better. But that doesn't mean the Depakote responders needed Risperdal, or the Risperdal responders needed Depakote-- or the other 40% got anything out of either drug.
It could be true that the effects are additive-- but this study doesn't show that. No study using "% of patients" can speak to synergistic effects. In other words, these studies do not say, "if you don't respond to one drug, add the second." They say, "if you don't respond to one drug, switch to another drug." They don't justify polypharmacy. They require trials at monotherapy.
So you may ask, well, do two drugs lower mania better than one drug, or not?

Depending what week you look at, MS alone reduces the score by 13; two drugs gives you another 3-6 points. On an 11 question scale, rated 0-4. So no, it's not better.
I have yet to meet someone who doesn't interpret these studies as supportive of polypharmacy, and it's not because they aren't critical. The reason for the blindness is the paradigm: they think-- want-- the treatment of bipolar to be the same as the treatment of HIV, or cancer, or pregnancy. The important difference is that these other diseases are binary: once you get them, nothing you do makes it worse. Take pregnancy. If two chemicals combined lower the rate of pregnancy, it is clearly worth it to take both. One chemical might have been enough, but who wants to find out? So you take the risk, and you eat both. This is also my argument against making Plan B OTC. Bipolar is not like this: if one or two drugs in succession fail, or things get bad, you can always resort to polypharmacy later.
Again, it may be true that polypharmacy is necessary. Maybe 3-6 points are needed. Maybe two drugs gets you better faster. But it can't be the default, it can't be your opening volley. Because I can't prove two drugs are better than one, but I can prove they have twice as many side effects, and are twice as expensive.
At minimum, if polypharmacy is successfully used to break an acute episode, you should then try to reduce the dose and/or number of drugs.
Now, here's the homework question: if all these antimanics have about the same efficacy, and polypharmacy should be third or fourth line, why do we start with Depakote? Is it better? Safer? Cheaper? What are the reasons behind our practice?

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===== ====== ===== The Last Psychiatrist: More On Amygdala, Anxiety, and MRIs
After the last post, I thought, "perhaps I was too broad. Maybe too political, maybe I didn't have enough concrete examples."

Then I opened my mail.

What I found was the most recent issue of Primary Psychiatry, in which appears Imaging and Genetics: Future Applications in the Emergency Room.

It reviews the literature on the neurobiology of aggression in precisely the way I was railing against in the earlier post: sufficiently vague that it makes people think this is alerady established, common knowledge.

The amygdala, located in the temporal lobe, has been shown to be associated with aggression and violence. Studies(29) have found a high rate of atrophy, as much as 20%, of the amygdala in aggressive and violent patients.
Note: studies (plural) but one reference. Note: you can't tell if 20% is a high rate of atrophy, or if it means "high rate of people who have 20% atrophy." And you're not supposed to know, because the point is simply to make you feel secure that his overall thesis is well supported.

But, according to reference 29, in a study of aggressive patients, only 20% of them had any amygdala atrophy (e.g. the other 80% didn't.) The amount of atrophy was fairly small.

Furthermore, that reference was a study of aggressive vs. non-aggressive epileptics. In addition to differences in aggression, the subjects also differed in IQ (lower IQ in aggressive group) and a history of encephalitis (associated with smaller amygdalas.) The study could well have been resubmitted: "A Couple Of People With Low IQs And A History Of Encephalitis Have Kind Of Smaller Amygdalas. We Think."

Here is the next sentence:

Imaging studies9,10 have also shown abnormalities in amygdala functioning, including decreased activation of the amygdala during affective stimuli in psychopaths
I'm sure whatever imaging studies they were doing 12 years ago were crackerjack, and based on two of these (which are the same data), the reviewer concludes psychopaths have decreased activation in the amygdala.

Which isn't what the studies found anyway.

First, the study didn't measure just psychopaths (e.g. antisocial PD), but psychopathic murderers who were incarcerated and legally insane. Note how the author extends these findings to psychopaths in general.

Second, it didn't find decreased activation in the amygdala, it found the opposite: higher activation on the right, and no difference on the left. Do you know the relevance of it being right vs. left? Of course not.

So the studies say: "psychopathic murderers have increased activation on the right." The reviewer summarizes: "psychopaths in general have decreased activation overall."

You would think that difference matters, but it doesn't, because the point of the review article isn't to teach you information, e.g. what happens to the amygdala, it is to convince you that aggression is biologically mediated. These articles succeed because it is established that no one will check whether it is actually increased or decreased (note that three reviewers did not check), because no one cares whether it is increased or decreased, because we all know those are just silly details.

I may as well point out that the studies referenced here didn't even measure the amygdala, they measured the subcortex (amygdala, hippocampus, midbrain, thalamus, together). Take that, precision instruments.

II.

In fairness to the psychiatry review author, the authors of the above references jumped to an even worse set of conclusions based on their own data

Raine et al. speculate that excessive subcortical activity contributes to an aggressive temperament in both types of murderers, but that "while predatory violent offenders have sufficient left prefrontal functioning to modulate such aggressive behavior in a way to bully and manipulate others to achieve desired goals, affectively violent offenders lack this prefrontal modulatory control over their impulses, resulting in more unbridled, dysregulated, aggressive outbursts." (bold mine, emphasis theirs)

and then published this in a forensic journal. Do you see?

The entire article is filler. All he wants to say is this single sentence:

In effect, research is supporting the notion that repetitive acts of aggression are grounded in a neurobiologic susceptibility.
This is simply not true. There may be aliens in the universe, but it is false to say, today, "in effect, evidence is supporting the notion that aliens can and do live in the universe." All we know is that there are studies that show a relationship between specific behaviors and specific anatomical areas. However, we do not know the nature of that relationship.

We cannot accurately quantify the behaviors and distinguish them from similar behaviors (is it aggression out of fear, anger, horniness, temporary insanity, or a combo?), and we can't adequately control for billions of confounders (3 red wines/d vs. 3 beers/d, bad parents, too many horror movies, frequency of one night stands, etc). How then can we relate them to inadequately characterized anatomical regions using machinery with the precision of an icepick, and then conclude "predatory violent offenders have sufficient left prefrontal functioning to modulate such aggressive behavior in a way to bully and manipulate others?"

We tend to focus only on one error, e.g. MRI false positive rate. But these studies don't take into account all of the other errors. It is the problem of significant digits: 3.225 x 5.23441 x 7 does not equal 118.16680575. It equals 100.

III.

You all think I'm exaggerating. That I am punching windmills.

In keeping with this development, sometime in the future cord bloods will be taken routinely from birth and used to delineate the individual's DNA so that genetic information will be readily available under emergency conditions to assure proper assessment of violent people. Hence, a patient presenting with an episode of violence and a history to support that will have their DNA contrasted with norms to determine if they have a predisposition to aggression and violence...
I have enough rum to get through the rest of my life, but the rest of you would do well to heed my warning: if you do not rein in your social scientists, your civilization is doomed.

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===== ====== ===== The Last Psychiatrist: More on Medical Competency

The primary rebuttal to my thesis of personal autonomy is, "well, we doctors are just trying to do what's best for the patient." This is categorically false (words chosen carefully.) What they want is what's best for that particular medical issue because it leads to the betterment of the patient; but this is not the same as taking the patient's life in total and deciding what is best overall for their lives.   What the patient wants in their lives may be, to them, worth the risk.
And I'm not saying the doctors aren't trying to do what they think is best; but you don't think George Bush, et al, are doing "what they think is best" for us? (Before you give a reflexive answer, grow up.) Allowing doctors extraodinary powers to treat against one's will is no different than executive privilege, an example chosen carefully because it highlights the political/societal nature of the process, over the scientific.

Here's an example. It is almost axiomatic that a person with a hemoglobin of 4 who refuses a transfusion is incompetent. Nothing they could say could possibly justify their refusal-- except that they are Jehova's Witnesses. I observe psychiatrists routinely dismiss these evaluations, and they're inwardly proud of their progressiveness: "No, he doesn't need an evaluation, he can refuse, that's his religion, his personal beliefs."   1) This seems pretty preposterous; are you saying cultural dictums outweigh personal choice? A person can't choose, but his culture can choose for him? 2) Is it possible that even a Jehova's Witness might actually want a transfusion but feels pressured by his peers to refuse? Isn't this more properly the purview of psychiatry-- helping people deal with the pressures in their life-- rather than the lazy preemption of personal choice? 3) Is it possible-- maybe, I'm just asking-- under the right circumstances-- that even a Jehova's Witness could be incompetent? I'm just speculating-- that their refusal is due to delirium?
And let's not discount expediency, whereby the doctor simply doesn't have the time to wait for the patient to get on board the treatment trolley. e.g. primary medical team wants to put a guy on IV antibiotics, but the patient refuses, he wants to go home. Most of the typical debate surrounds their mental state, and not the following simple question:
ME: Well, if he refuses, what are the alternatives?
THEM: We'd have to discharge him on oral antibiotics.
ME: Would this work?
THEM: Well, it's not ideal. There's a good chance he'd end up back here in the hospital in a few days.
ME (not punching anyone): if he has someone at home who can help take care of him, etc, he, unfortunately, (squeezing the thumbtacks in my hand) has the right to refuse.
THEM (frustrated, angry): Fine. Whatever. They have to sign an AMA discharge, and know that we're not responsible for what happens.

Note the final aggressive maneuver.   It's the only thing they can do to "punish" the patient-- for not doing what they wanted. It's more clearly seen when I say this:

ME: Unfortunately, (tacks in hand again) his refusal doesn't discharge our obligation to treat. He'll need an outpatient appointment within a day or so.

THEM: No, I'm not doing that. If he doesn't want to follow my prescribed treatment, I'm not going to alter my schedule for him.

ME: Unfortunately, if you were ready to find him incompetent and keep him in the hospital, lawyers won't understand why you didn't follow such a sick person more closely as an outpatient.

I always blame lawyers, not because they are to blame, but because it's the only thing doctors really understand. But either the patient is really sick, and we can have a discussion about incompetency, or they're not, and we shouldn't be having the discussion.

Another piece of idiocy I get from other doctors is this: well, would you want your mother to refuse? Exactly what in the word mother presupposes an inability to make decisions? But they miss the crucial point: that even if she was incapacitated, the person who would decide for her would be-- me. Her family, or, if necessary, a judge. Substituted judgment. Consequently, the family would have to be involved anyway-- so involve them now.

Rather than force a family member to have to go against her wishes to do what is in "her best interest," it would be better to help them convince her to do what you think is best. The time spent during the consult should be devoted not towards assessing their competency-- let's face it, if you can't tell in five seconds that they're incompetent, then they're probably competent-- but towards educating the patient, conveying some empathy and assurance, and getting them to choose for themselves what is best for them.

Because some day in the future they're going to get sick again, and they may be much less interested in coming back in for treatment if they think we're going to just do what we want to them.

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===== ====== ===== The Last Psychiatrist: More On Medical Journals
A commenter suggested another good one, so I added it.

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===== ====== ===== The Last Psychiatrist: Moriarty

See? I told you he was in Styx.

(Thanks to Fargo Holiday)

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===== ====== ===== The Last Psychiatrist: Most Common Cause Of Bankruptcy Is Catastrophic Medical Bills
Why I drink.

Here is the simple reason while there will never be any kind of serious healthcare reform in this country absent a war: no one cares. About healthcare itself-- it's just a proxy for ideology. Everything you hear are lies, damned lies, and Harvard.

WASHINGTON (Reuters) - Medical bills are behind more than 60 percent of U.S. personal bankruptcies, U.S. researchers reported on Thursday in a report they said demonstrates that healthcare reform is on the wrong track.

I'm puzzled by the term "U.S. researchers." They are Harvard academic researchers funded by the Robert Wood Johnson Foundation. Is this to distinguish them from "French researchers" who presumably have more/less credibility depending on your politics; or is it a slip of the tongue suggesting they are actually working for the U.S. government?

...Harvard's Dr. David Himmelstein, an advocate for a single-payer health insurance program for the United States...

What do the authors want to be.... oh, never mind.

II.

60% is a big number.   Wow. I didn't realize it was so high! What I need now is a striking metaphor that will move me solidly towards populism:

"Unless you're Warren Buffett, your family is just one serious illness away from bankruptcy."
Nice. Sounds a lot like

"Unless you're Bill Gates you're just one serious illness away from bankruptcy."
which is what the the same guy said four years ago. Either Gates got richer, Buffett got poorer, or they haven't learned much after 4 years of careful study into this problem.

That would be a sign that numbers are less important than ideology.

III.

I get conflicted because I'm for the same thing he is for, a single payer system (with modifications), but studies like this one and people like this guy make me react negatively to it. It actually makes me want to drink. I realize it's shooting my face to spite my teeth, or something, but these academics who stagnate in their sycophancy drive me straight to the rum.

The study is not published yet, so I have to rely on the news report, which is like relying on your wife's lover to tell you which bottle isn't the cyanide. But here goes:

Using a conservative definition, 62.1 percent of all bankruptcies in 2007 were medical; 92 percent of these medical debtors had medical debts over $5,000
I realize I may be out of touch with the common man because I'm a wealthy industrialist who wears a monocle and a top hat, but are you telling me that 60% of all of the bankruptcies in the U.S. were because of $5000?

It's a good guess that people were in debt with other things as well, right? Credit cards? Car loans? Home equity loans?   But blaming it on medical expenses is a more politically lucrative spin. No, I can't prove it. I can, however, prove the authors are up to nonsense: in their last study (four years ago) with similar findings, they conflated "medical bills" with missing work due to illness even if there were no medical bills. They didn't have high bills; they had no income.

This isn't an argument for universal healthcare; it's an argument for disability insurance. Which, by the way, even doctors don't bother to get. It's expensive and complicated and boring.

Disability insurance doesn't lend itself to ideological battles. You can't get self-righteous about it. You can't hate Pharma for it.   You can't get a Harvard faculty position for studying it.   Truth doesn't come from God or physics, it comes from the potential of grant money.

It's good to keep this in mind as you hear people argue violently about something they neither understand, nor really care about.

IV.

Here's what was buried in the paper, towards the end:

Many debtors described a complex web of problems involving illness, work, and family. Dissecting medical from other causes of bankruptcy is difficult. We cannot presume that eliminating the medical antecedents of bankruptcy would have prevented all of the filings we classified as "medical bankruptcies."

It's hard to know how you'll end an article once you permit yourself to ignore the facts and make them submit to your worldview. But a good guess would be:

In 1591 Pope Gregory XIV fell gravely ill. His doctors prescribed pulverized gold and gems. According to legend, the resulting depletion of the papal treasury is reflected in his unadorned plaster sarcophagus in St. Peter's Basilica. Four centuries later, solidly middle-class Americans still face impoverishment following a serious illness.

Do any of these clowns realize that this example is precisely why universal healthcare is the wrong solution to the problems they are describing?

(also, see my response to a comment, below; then final word here)

-----------------------------

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Most Frustrating Technology of 2010 (so far): Google Android

if I see this thing in my house, I'm stabbing it

I'm posting this here because I have no where else to turn, maybe someone can help me. Or, I can just publicly shame Yahoo and Google.

The Motorola Android (Verizon) does not connect with Yahoo! Mail properly. There are two big glitches:

1. Deleted messages reappear the next day, and read messages re-highlight as unread. There's no predictability or periodicity to this. It can happen in an hour, or in two days.

2. When you reply to an email on the Android, it saves thousands of copies in your Yahoo! sent mail box. Last night I deleted 46000 messages.

This is what I've done so far. I've followed the Verizon and internet directions:

Make sure Wi-Fi is turned off
Press the E-Mail icon (the default Android E-Mail application)
Enter your Yahoo E-Mail address and password
Press "Manual Setup" in the lower left hand corner
For "Incoming Server Settings" set the IMAP server to "imap.mail.yahoo.com" and the Port to 143
For "Outgoing Server Settings" set the SMTP Server to "smtp.mobile.mail.yahoo.com" and the Port to 587
Check "Require sign-in" and press Next
Select how often your Droid will check for Email, and choose default options
Give the account a name and set your display name for outgoing messages
With these instructions the phone deals with email properly except for the two glitches noted above.

I have tried variations:

Removed the "mobile" in step 6 (so it is just smtp.mail.yahoo.com). No.
I have turned off the "saved sent messages" in the Yahoo! Mail account options. It still saves.
I have entered the username as both" [email protected]".com and just XXX. No.
I have tried this with the free Yahoo! Mail as well as with the paid Yahoo! Mail Plus. No.
I have tried driving over it. No.
I have tried changing the outgoing settings to plus.smtp.mail.yahoo.com as well as plus.smtp.mobile.mail.yahoo.com

I realize I can just switch to GMail, but if anyone knows how to resolve this, please let me know.

Update:

7. I tried changing the incoming mail server to imap.n.mail.yahoo.com. No.

I determined that the copies are made each time the Android connects to Yahoo to check for emails, e.g. every 15 minutes, every time you send another email, or every time you hit refresh. It makes 2-3 copies each time (can't figure out why) but over the course of a day...

Update 1/24/10

The problem appears to be hardware or carrier, not software. The Motorola Droid runs 2.0 and has the problem, while mytouch runs 1.8 and is free of this abomination.

However, the Nexus One on Tmobile has the problem, too. ~~He said he fixed the problem by removing himself from his Contacts. This did not work for me (I wasn't in the contacts.)~~ (Nope-- this turned out not to work.)

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===== ====== ===== The Last Psychiatrist: Most Prescribed Drugs 2009: Post 1, JFK to SFO

I'm sure we have a pill for that

(The Air Tran challenge: they offer Wifi on my flight, so how well can I use it? Post 1.)

In 2006 I offered you the Top 25 psychiatric prescriptions.

Want to see what's changed in 2009?

The decade long WMD that was Depakote?   Does anyone want to apologize for that? Hello?

II.

You have to dig a little bit. Look at Wellbutrin XL, at 2M, down by 73% from 11M. But bupropion (generic Wellbutrin) is up, at 8M. Add the two together, and you're back to 11M. This doesn't even account for generic bupropion SR + Wellbutrin SR. So in this case, the company isn't marketing the branded drug, but doctors still want to use the chemical.

This makes it hard to argue that it's Pharma that is pushing the "overprescription" of Wellbutrin (in contrast to Prozac, which has fallen.)

Meanwhile, Risperdal is up-- but it's generic now. So why up? Because many insurance plans ask for it first. Same with Celexa, which is the "generic" of Lexapro (I know, I know). Add the two together, not much change.

But what is evident here are three trends:

SSRI/SNRIs are on the way out, except for Cymbalta.
antipsychotics are up, probably taking over for antidepressants
antiepileptics appear to have been a terrible, embarrassing fad.
either more people are on medications than in the past, or the same number of people are getting more medications.

III.

In 2008, drugs sales rose only 1.8%. in 2009, by 5%. Those are both low. Very low.

Yet:

number of generics exploded to 75% of prescriptions in 2009, up from 57% in 2004
number of branded drugs fell by 8%
total drug sales climbed to $300B (more spending on drugs).
But generics only accounted for $75B.

In other words, even though we are using way more generics, we are either: using more medications than ever before (as above); or the few branded ones we are using are even more expensive than ever.

That turns out to be the case: specialty drugs (e.g. Avastin) for chronic illnesses jumped to 21% of the sales.

If you couple post-Obama American medicine's (and I'm not blaming him) focus on preventative medicine and long term maintenance-- where Big Clinics and Big Insurance will be the winners; with Big Pharma's move away from expensive acute treatments to really expensive long term treatments, you almost have to wonder if that's more than a coincidence?

III.

Here's the punchline: there's a little over $100B in waste (pdf) due to outright noncompliance, according to Express Scripts. This number is undoubtedly high, because it is based on monthly refills-- for example, if it takes you 40 days to use up a 30 tablet supply, then you'll use only 9 scripts a year. Based on this, they estimate a compliance with antidepressants of 83% (i.e. 10 scripts a year). However, psychiatrists (unlike most other specialties) ask you to come back every month or two months at which point you'll get a new script- regardless of how many you actually have left. No one says to their psychiatrist, "you know, I still have a lot of Cymbalta left over from the last script." So the actual noncompliance is likely much higher.

In other words, while prescriptions may cost a lot, the real budget killer is waste, thrown in garbage cans or flushed down toilets.

IV.

And I'll say what no one dares say: how many times does a patient agree to "take" Zyprexa and Effexor just to get the Klonopin?   Or Lipitor and glucophage, just to get Percocet? True story: there's a pharmacy I walk by on the way to the sketchy city movie theatre, and every time I pass it I see guys tossing full pill bottles into the outside trash can.

V.

The solution: have Pharma pay for the first 30 days of any treatment (e.g. vouchers.) Only after a patient has been on it for at least a month should the insurance cover the rest; this cuts out the wasted one or two or three first attempts at medications ("I didn't like the Cymbalta, so I stopped it.")

Copays, hated by all, are a necessity: free medications are not valued by patients/humans; nor should the copay be subsidized by medicaid or other plans. Five dollars is enough.

And, finally, the most hated of all (choose a or b):

a) all prescriptions should require a prior authorization by the doctor, and a supplemental one every six months. The easier it is for docs to prescribe, the more they will prescribe. Now you'll think twice before you add on the Buspar.

b) you make all medications full access, and priced however Pharma wants, but you give each doctor a pharmacy budget, e.g. $20/patient per month.

Another reality no one wants to hear: doctors will have to accept managed care at the treatment level (e.g. formularies) or they will have to accept managed care at their reimbursement level. Or both.

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Murder-Suicide

Just thought you should know:
There are about 1200 murder-suicides per year (i.e. 500-600 suicides by the person who just killed someone else).
75% involve the boyfriend/girlfriend or spouse; 96% of the murderers are males (duh)
92% involve guns
92% occur in the house of the victim
There is an average 6 year age difference between the murderer and his victim. Risk increases with widening age difference.
23% of murder-suicides (say, about 130), the murderer is 55 or older. Contrast this with the general homicide rate by 55 year olds: 5%
Contrast this with the suicide statistics in the general population, and I think you'll agree that there are an amazingly high number of people dying at the hands of their idiot boyfriends/husbands.     "You don't understand, I loved her, I'd do anything for her, and she lied, slept around-- all that time meant nothing to her-- she wouldn't listen! How can she just take what we had and just throw it away? It doesn't make any sense!"
The societal question is what has happened to many men that they are unable to define themselves, or affirm their value, except through another person. And "love"-- or its distortion-- and aggression are closely linked in such people. But that's narcissism, and it's the disease of our times.

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===== ====== ===== The Last Psychiatrist: "My daughter deserved to die for falling in love"

Really? Was that the reason?

The article from The Observer currently making the rounds: a 16 year old girl in Iraq is killed by her father because she "fell in love" with a British soldier.

It was her first youthful infatuation and it would be her last. She died on 16 March after her father discovered she had been seen in public talking to Paul, considered to be the enemy, the invader and a Christian. Though her horrified mother, Leila Hussein, called Rand's two brothers, Hassan, 23, and Haydar, 21, to restrain Abdel-Qader as he choked her with his foot on her throat, they joined in. Her shrouded corpse was then tossed into a makeshift grave without ceremony as her uncles spat on it in disgust.

Count the players: the father, two brothers, and some uncles. For completeness, she was kicked and beaten, then choked by standing on her, and then stabbed.

He was arrested, but released in two hours.

Abdel-Qader, a Shia, says he was released from the police station 'because everyone knows that honour killings sometimes are impossible not to commit'..The officers were by my side during all the time I was there, congratulating me on what I had done.'

Though I doubt anyone in this country would sympthize with this nut, there is a certain deference to the notion that some cultures have honor killings, as if that is sufficient explanation; as if merely abandoning that practice will solve the problem.

But what really is going on here? We can try to frame it in terms more real to us: pretend this is a Jewish family and the British soldier is a Nazi. Let's add that the Nazis have already killed this man's brother, and raped his sister; let's say that the Nazis even did this right there in front of the 16 year old girl-- yet she still falls in love with the Nazi soldier.

In this context, we can better understand the anger, the betrayal, the incredulity-- "how the hell could you...!!!" But none of this explains why he killed her:

'I don't have a daughter now, and I prefer to say that I never had one. That girl humiliated me in front of my family and friends.'

But what we can't yet get at is the humiliation. And that's where the fire is; that's why she was murdered. Everything else is smoke.

This is narcissism, bold and pure. It seems like it may not be because there are so many other people involved, but it is, institutionalized and mainstreamed.

The general problem with the narcissist is that he can't see the other, he only sees others in relationship to him. It's a movie, or a video game. It's Grand Theft Auto. Sure, the other characters are real characters, but what matters is you. You don't even have to be a good guy, or the best guy-- just the main character. It is impossible to conceive that any of the characters in GTA can have thoughts that aren't about him. "But it's a game, it's not like real life." No, to the narcissist, "real life" isn't real either, it's simulacrum. Every action is about him, positively or negatively.

That's why it doesn't matter to this nut what actually happened-- the article explains that the soldier probably didn't even know she had a crush on him-- and the father knows this. But what happened isn't relevant at all, what matters is how it impacts him. It would have been explicitly preferable to him that the 16 year old have sex with the soldier but no one ever could find out, then allow to be made public the possibility that such a thing could theoretically happen, even if it didn't. Denial is a psychological defense; reality is not.

That's why his mind-bendingly inane position on homosexuality makes complete sense to him:

Homosexuality is punishable by death, a sentence Abdel-Qader approves of with a passion. 'I have alerted my two sons. They will have the same end [as Rand] if they become contaminated with any gay relationship. These crimes deserve death...

Umm, why not just simply say, "my sons are not gay?" You wouldn't think to tell your sons not to have a gay relationship unless they were, in fact, gay-- and we can assume these kids are not gay; the solution to this crazy logic is that it doesn't matter if they are gay or not; he doesn't know, doesn't care, doesn't need to even think about it-- they don't have identities at all, only he has an identity, everyone else is an extension of it.

That's why he can say, with a straight face, that he has no daughter, that he never had one. Reality doesn't matter, her own identity doesn't matter, only his.

The article seems surprised that this man shows no remorse. That's not surprising at all: narcissists can't feel guilt. They only feel shame. Guilt means you know you are wrong, but the narcissist sees himself as above the law; he either makes appeals to a higher law, or thinks he better understands the spirit of the law as applied to the current situation ("Stealing may be wrong, but right now...")

Shame, however, means you are caught doing something wrong, and so people get to decide how to see you, and see you as less. This is the narcissistic injury. You can't convince the other person you are more than what they see. "Wait, it's not how it looks! I can explain-- why won't you let me explain?!"   That's why narcissists aren't loners: they need the reinforcement of their identity from other people, as a bulwark against reality.

You may ask why I focus so much on narcissism, and it is precisely because of things like this. Flip the coin of narcissism and on the reverse is always violence. ALWAYS. Violence isn't always necessary, but it is always available. Institutionalized narcissism is necessarily the penultimate step to war.

Which brings us back to daughters. Women don't count for much as it is; when other people don't have identities, when what they do is always about you, then you can see why being in love with a Nazi, or British soldier, is such a huge issue. She didn't do it-- he did it. He's not banishing her-- "I'm never talking to her again!" -- he's making sure everyone knows he's not going to do it again.

In America, there's always an appeal to genetics as a mitigating factor. He does it, too:

He said his daughter's 'bad genes were passed on from her mother'.
Except he isn't saying she is less to blame for her genetically predetermined behavior, of course, he's saying he is less to blame.

Rand's mother, 41, remains in hiding after divorcing her husband in the immediate aftermath of the killing, living in fear of retribution from his family. She also still bears the scars of the severe beating he inflicted on her, breaking her arm in the process, when she told him she was going. 'They cannot accept me leaving him.'

Of course not. It's his video game. How could you leave on your own volition? How did you get volition?

'Even now, I cannot believe my ex-husband was able to kill our daughter. He wasn't a bad person. During our 24 years of marriage, he was never aggressive. But on that day, he was a different person.'

No, he wasn't a different person. She was. That's the whole problem with narcissists.

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===== ====== ===== The Last Psychiatrist: My Fellow Americans: The Speech President Bush Should Give

As government officials flounder trying to explain why the most important fiscal maneuver in U.S. history is so necessary, I offer a potential Presidential speech. With footnotes.

I.

Good evening.

I come to you as a President at the end of his term, who suddenly must deal with the largest issue of his Presidency. I have already had the difficult responsibility of leading this nation during other historic crises, and I am aware that the country is quite divided on my legacy and performance. It will be up to history to give the final verdict.

But the current crisis before us now is too large, too immediate, and too catastrophic to be trivialized with partisanship, blame, or scapegoating. If all goes well, there will be time for that later. Senators Obama and McCain have agreed to temporarily suspend their campaign to work within Congress, and they are to be commended for that; but, indeed, they had no choice. If quick, decisive and herculean action is not taken in the next few days, then the country they seek to lead will cease to exist as they know it.

II.

A summary of the events are these:

Financial institutions over the course of decades took on greater and greater leverage in order to maximize their profits.(1)

Simultaneously, every day Americans, in pursuit of the American dream, worked and saved money to buy a house. In recent times-- the past two years-- housing prices had risen so dramatically that many could not afford the house of their dreams-- except for the availability of credit, of low rate mortgages. Some of these mortgages required no money down, an offer too tempting for many trying to put down roots for their families.

As is inevitable, cycles end; and housing prices began to fall. For many, the price of the house fell below their mortgaged amount-- they owed the bank more than the house was worth. In effect, not only could they not afford to live there anymore, but it made some economic sense simply to let the bank foreclose.

Critically, for most Americans who work day to day and live off of their incomes, who have little savings and perhaps even considerable debt, their entire financial wealth is in the value of their homes. Why this should be the case in a nation as prosperous as our own is another matter that will need to be addressed. But it cannot be now; there is no time.

And the two worlds collided. Mortgage defaults meant that financial institutions that relied on those mortgages no longer could count on that money; but worse, they had leveraged and invested that money at 10 times, 20 times.(8) If they lost a dollar, they really lost 20. On paper, with the mortgages essentially valueless, these institutions were bankrupt.

And the spiral continues.

Lacking even the money to cover their own leverage, they are unable to make new loans, or the loans will come with prohibitively high interest rates.
So mortgage rates go up, not down; and there will be more defaults. And housing prices fall further, worsening the cycle.
As property values fall, so too do the property taxes which pay for the schools which educate the community's children.
No car loans, no school loans. No personal loans.
No loans to help with medical bills, the chief cause of bankruptcy in this country/
Small business will be unable to get short or long term loans-- to get mortgages, to pay their leases, to make down payments-- to pay their employees.
Unemployment rises; economists believe the rate could go as high as 25%.(3)
More people will default on their credit cards-- how would they be able to pay them? And credit limits would contract dramatically, if not completely vanish. On the one hand people lose their jobs, and on the other hand there is no credit available to tie them over.
Pensions, 401(k)s, own shares of these financial companies. There are millions of retirees right now, at this moment, who are worrying how they will make it now that their 401(k)s have been cut in half. If we do not provide a bailout plan for these financial institutions now, we will be bailing out millions of retirees later.

Without immediate action, lenders will be too suspicious that borrowers will default; and citizens will be suspicious that their banks, their mutual funds, their 401(k)s, will not be solvent. The credit markets will freeze; banks will fail. Months ago, IndyMac, a small bank, failed. If a larger, well known bank fails-- Wachovia, Washington Mutual, or any number of others-- the public may indeed panic about their own savings. There will be a run on the banks. This is not hyperbole, and I say it again: there will be a run on the banks.

To be clear: this is also a national security threat. We-- both the government and private institutions-- send aid and do business all over the world. All of this is threatened. The crisis has spilled over to many of our European allies, who only months ago worried about possible inflation as their economies grew robustly. But no more. Meanwhile, Iran has announced the end of America, and other countries lie in wait, hoping to pick at the American carcass, at firesale prices.

III.

Perhaps some of you can't believe the crisis is that bad, and are of the opinion that, as with every other crisis this nation has ever faced, we will come out ok, even on top. You believe this because you believe in America.

It's a safe bet, but I remind you that we have overcome these past crises not by waiting, not by debate, but by commitment, action. We have been fortunate that in most cases, the burden has been borne by some who accepted the responsibility, and has not been generalized to everyone; indeed, that is one of the strengths of this nation.

Indeed, Secretary Paulson, Chairman Bernanke, and countless others assured me and the American people that the financial system was sound, that it would recover on its own. Perhaps more aggressive action a year ago could have prevented this. They were wrong, in retrospect. I was wrong.

But this may not be the case now. I have come to you now because I believe that you, the American people need to, and are strong enough to, hear the facts.   And it is imperative that all Americans-- including those in the government-- understand that the stakes are real, and are not just high, but ultimate. There is no time to debate blame, history, or social policy. All personal or partisan motives must be set aside.

But we have a plan, a good one, not without drawbacks. But it can be implemented immediately and fine tuned over time. And it is the only plan available to us.

Secretary Paulson has shown considerable leadership on this issue, and it is this country's good fortune to have a former Wall Streeter working now for our side. He understands the complexities of the problem, and has carfted a plan which will likely succeed.

The specifics of the plan are these:

The bailout plan will cost $700 billion dollars, but three things must be understood.

First, the money will not be spent all at once. It will take months, perhaps years to spend it, a little at a time, as needed. While $700 billion will be budgeted for this crisis, not all of it may actually be spent. (4)
Second, the money will be used to buy assets, such as mortgages, that no one else wants to buy now. These assets still have considerable value-- just not today, not this week.(2) It is reasonable to assume that at least 70%, if not much more of this money will be recovered as real estate stabilizes. This will be done with warrants, a key requirement of the Democrats, which will assure that the government gets paid first, before the banks. Consequently, the burden to taxpayers may be very small, if indeed there is any.    It is entirely likely that the government could realize a profit over the years, though this is not the purpose of the bailout, The U.S. Government is not a hedge fund-- it has more important work to do.
Third, $700 billion is not just the price of the assets, but the price of confidence. A lesser amount would not convince the American financial system that there is plenty of credit available should they need it-- for an emergency, to conduct business. To know that they can take a calculated risk and begin lending again. Indeed, with the restoration of confidence, with the flowing of the credit markets, troubled financial institutions may-- will likely-- try to raise their own capital to fix their own balance sheet.

IV.

Americans want to know how this will be prevented from happening again; indeed, many worry that a government bailout poses moral hazard, only gives license to overleverage again. This will not happen, and part of the long term solution is an entire overhaul of financial regulations, compelling increased transparency and limits on leverage. Congress is highly motivated in this regard as well.

Why would we want to bail out the very bankers and executives who caused this in the first place?    In some instances they were complicit in a Ponzi scheme; in some cases they were outright fraudulent. These people will be held accountable, but that is not today.

Punishing the arsonists can only happen after putting out the fire.

It is entirely understandable that Americans want the CEOs responsible for overleveraging, for lack of transparency, and for poor judgment to be punished. Indeed, many of them have been, in the only ways that matter to them. They have lost their jobs, and they have been publicly shamed.   The FBI is also investigating certain institutions for improper actions.

Some, like Ron Paul, see this plan bailing out the very institutions which, by the hand of the free market, should fail. Unfortunately, the problem is much larger than just a few institutions-- nearly all institutions will be affected by this. We are not saving the CEO of AIG; we are saving your money, which is in AIG.(6)

Why should you be punished because of the mistakes, or even misdeeds, of others? Should you lose your home, your savings, because some on Wall Street had poor judgment?

The time for blame is later.

Because as I am both the leader and the representative of the people, I will support the overwhelming desire of the American public and not allow CEOs a golden parachute in the government bailout. It is morally outrageous to allow them to be paid more money for leaving than the entire company is now worth.

But our anger has to be temporarily held. There will be time for that later-- there is none for it now.

Many worry that such a plan will lead inevitably to inflation. We are undergoing one of the largest deflationary periods in our nation's history. Money is evaporating from the system; credit is disappearing. People are losing their homes, their personal savings. Businesses are not growing. This plan is replacing the money that has disappeared (5), (7) and, over time, should prevent further deflation while simultaneously checking inflation. The lung has collapsed almost to nothing; the plan is to inflate it enough so that the patient can breathe.

Others scoff at the appearance of socialism, that we are nationalizing the financial institutions. This could not be more wrong; nationalization is what will occur if we do not implement this plan immediately.

I call on Congress to approve this plan. In the past months, there has been much talk about which institutions are too big to fail. In truth, there is only one: the united States of America. And we must do anything necessary to save it.

This is what is at stake.

My fellow Americans, good night, and God bless us all.

---------

1. For every dollar they had in reserve, they would lend out or invest $5. For this leverage they would earn rates of return on the order of 10%; this meant, however, that their actual return on the $1 they actually possessed was quite low; put another way, the only way they could get 10% return on their $1 was to borrow four more to invest.

Every other financial institution, hedge fund and brokerage had to be leveraged in greater and greater amounts, just to keep up. Now, leverage ratios are on the order of ten to twenty times.

2. An analogy might be to owning a Picasso, previously bought for one million dollars. One could try to sell it tonight on Ebay, but in the current climate perhaps no one bids-- so the price never goes above $10. Is the Picasso really worth $10? The bailout plan is to buy the Picasso at $30, and wait.

3. 9/25/08: jobless claims at 493000, the highest level since 9/11. Continuing claims-- 3.542 million-- is the highest since 10/03.

4. Neither does it significantly increase the deficit. As the money will be financing these failing institutions, the budget will show only the interest costs, and any actual losses, if any.

5. Money reinjected into the banking system, by new rules as well as fear, will not be able to leverage it out at 20x as before. e.g. Goldman Sachs, under its new "bank" status, can only leverage 10x, as opposed to the 30x in the past. This is clearly deflationary.

6. Since the governments acquisition of 80% of AIG for $80B, AIG's stock price has doubled. And the terms of the bailout were quite steep for AIG: 2% "gross commitment fee" ($1.7B upfront) and 8.5% interest. This is quite an incentive to raise capital some other way.

7. In July 2007 there was $2.2T in commercial paper; that number is now $1.7T. $500B has disappeared.

8. In 2004 the SEC loosened the leverage restrictions for certain institutions from 12x to up to 40x. Not coincidentally, all of those institutions either are now gone, or in a dramatically different form.

---

1/16/09 Update: I was wrong. First, the obvious: the TARP passed, and nothing much has changed. Credit spreads aren't as wide, treasuries look like a bubble, but hardly the effect $400B was supposed to have. But the thing that I was most wrong about-- in retrospect, how could I not have assumed this was going to happen-- was that the money wasn't used as it was supposed to be used. Rather than the govt. giving the banks money to lend out, the banks kept it. BAC bought some bank in China, etc. And then BAC implodes further. Yet everyone who works at BAC got paid... a conspiracy theorist might say this is enterprise corruption. Maybe it shouldn't just be conspiracy theorists.

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===== ====== ===== The Last Psychiatrist: "My fiancee is pushing me away and I've lost hope"

my advice can't be worse than his

Here is an Ask Metafilter question, and my reply. Maybe it will do someone else some good.

If you've already read it there, skip to IV, for what I could not include there.

My fiancee and I (both 23) have been together for just over 5 years and living together for the past 3. There have been ups and downs during that time, including a month-long break up about 2 years ago, but I love her and want to spend the rest of my life with her. She had a rough childhood (alcoholic father who left) and I think that this is negatively affecting our relationship and her self-image.

I had a female best friend from high school, who I knew before I met my fiancée, but I have largely given up this relationship because my then-girlfriend was jealous. It was a slow and ugly process and since then my fiancée has thought that I could and should find someone better suited to me than she herself is. I have tried my best to quell her insecurities, but they have been around for most of our relationship.

I proposed about a year ago and she said yes. Things seemed to be going well, but a few months later there was a conflict between my fiancée and sister at a wedding planning convention. I wasn't there, but my sister was apparently late and then didn't stay for very long, which my fiancée and her mother took offence to. Since then there has been tension between my fiancée and sister. This is even more concerning for me, since both of my parents are deceased and my sister is the only immediate family that I have left.

This past September was a terrible month for my fiancée, as her father died and she was laid off from her job. I tried to be as emotionally supportive as I could, but she didn't lean on me as much as I would have expected.

Roughly 2 months ago she started saying that she didn't feel right wearing the ring that I gave her because the diamond that I used is from my mother's wedding ring, and my fiancée thinks that the diamond should stay in the family (sister). I talked to my sister about using the diamond before I got the ring made and she was ok with the plan and the way I see it, once we get married my fiancée will be in the family anyway.

About the same time she told me that she had started taking anti-depressants. She said that she had thought about suicide, but had no immediate plans to do it in the future. I encouraged her to see a therapist, but she only took the pills which were prescribed to her. My fiancée stopped wearing the ring two weeks ago and a few days later she said that she really doesn't want to live anymore and that she has been pushing me away intentionally. I found her a therapist myself this time, and made sure that she went. She said that the therapist was insightful, but it hasn't made her change her mind. She said that she doesn't really want to go again.

We've tried talking about this, but she is emotionally distant and insists that I find another girlfriend so that she can leave me and not be missed. Feeling confused and unsure about what to do, I asked her best friend if she knew what was going on with my fiancée. She told me that she didn't know that my fiancée was thinking about suicide but that she did know that she was having second thoughts about the wedding and that she was stressed out about money.

So here I am. I'm scare and confused. I've tried my best to show my fiancée that I love her and that she deserves to be loved, but she is pushing me away. I'm tired of struggling to keep this relationship going, but now I'm worried that she will hurt herself if we break up. She seems to want to continue our normal day-to-day routine and act like nothing is wrong, but I just can't play this charade.

Any thoughts about this situation are welcome. I'm looking for some outside perspective to help me figure out what to do next. Let me know if I've left out any important details. Thanks.

II.

Here's my reply:

No. Please take this in the spirit it is intended.

You make it sound like your fiancee is suicidal; that you may be the only thing keeping her alive. Most of the Mefites' responses are about her depression. Yet your subtitle is: "My fiancée is pushing me away and after years trying to make things work, I've lost most of my hope."

"This past September was a terrible month for my fiancée, as her father died and she was laid off from her job. I tried to be as emotionally supportive as I could, but she didn't lean on me as much as I would have expected."

Her father dies, and what your radar detects that is amiss is how she treats you.

Do you think you know her better than anyone? I think you believe other people have more facts about her, but that you can interpret them better than anyone. That's unlikely, but even if it's true then this--

I asked her best friend if she knew what was going on with my fiancée. She told me that she didn't know that my fiancée was thinking about suicide but that she did know that she was having second thoughts about the wedding and that she was stressed out about money.

-- indicates that her best friend's view of the "facts" is that the problem is you/marriage, not suicide. But instead of considering what that might suggest, you move to:

So here I am. I'm scared and confused.

You wrote that you proposed "about a year ago." I wanted to get a sense of where your head was at around that time. Fair guess you got engaged in Feb 2011? At that time, you Asked Metafilter: "The Liberal Education ideal is ruining my life. Please help disabuse me of it."

It started with Mortimer J Adler and his 'How to Read a Book'. I bought it about two years ago, and shortly after that time I became fixated on the idea of getting a liberal education and reading the Great Books.

I also have a tendency to avoid my university studies to look for "something else", some other activity or field of knowledge which will bring satisfaction to my life. I'm not sure if this is strictly procrastination, or if its something more. I started with reading books from Adler's list and other similar lists on the internet... Then I rekindled my learning of French. I've given up on the idea of learning to play an instrument, but I feel like I ought to, and I occasionally browse the web for pianos and piano lessons.

This much I could handle reasonably well, but then I found the The Teaching Company and The Modern Scholar. ...I've downloaded most of the courses that I could find through torrents, and have since been listening to the lectures for an average of 20 hours each week for the past 7 months.

I also need to find a job as my savings have nearly run dry.

I'm guessing I have a combination of an inferiority complex, a habit of procrastination, and a tad of neuroticism thrown in for good measure.

Somewhere around this point you asked a woman, "honey, will you marry me?"

And this is worth asking: what does it mean when a college student turns to the Teaching Company for a liberal education? College has failed you. Demand your money back. But you didn't really want a liberal education, you wanted to be... smarter.

A month later you Asked: "How can I feel good about finding a job and starting a career?" Not how can you get a career-- how can you feel good about it?

I'm an economics major who doesn't know what the hell he is going to do for a career after graduating, and frankly doesn't feel qualified to do very much. I went into university thinking that I would try for medical school, but I was one of those kids in high school who got good grades without trying very hard, and my nearly non-existent study habits have left me with a C average, although even that has been slipping lately. Now that I'm nearing the end of my academic career, I'm starting to freak out about my career potential, and the related anxiety has me neglecting school work even further.

Last year in a labour economics class, my prof stated that first jobs after college correlate with lifetime earnings. This has also added to my worrying, and I have been putting off getting a much needed part time job (partly) because of it.

The future is indeed terrifyingly unknowable when you can't even focus on the present.

III.

I go through all this not to embarrass you or criticize you but to show you two things: your life around this time is marked by ambivalence, anxiety, uncertainty, yet you decide to get married. But of course it makes sense that you would try to lock down at least one aspect of your life. You chose marriage-- which is typically what girls do when they're looking to be taken care of, to be defined by someone else. Right?

But what if she's as ambivalent as you about the future, but she wants something else (other than marriage) to lock down? Now a marriage is one more burden of uncertainty she has to carry around with her.

The second thing all this shows you is what your words reveal: that you are intelligent, interested, eclectic, hungry-- AND you are very conflicted, ambivalent, and uncertain. These aren't psychoanlayses, these are explicitly your words. This is the message you want people to hear. If I can see all this just from Metafilter posts alone, it is absolutely certain that your fiancee knows it. Maybe she senses that you're grasping on to her because she's an anchor, and she doesn't want to be an anchor, she needs an anchor. Most women don't want to be responsible for their man's stability, and she sounds like she wants some attention all for herself, of her own. Maybe she doesn't want to be married, maybe she's depressed, maybe she...

...regardless of the reason, she needs to get help, a therapist, and you need to get focused and NOT a therapist. Your problem is not unique: too much freedom. If you were stupid you could plug into the system easy, one talent= one job. But for you there are too many possibilities.

Your parents being deceased, being in college, being smart... that's the ether in which a naturally worried, "is this good enough?" young man finds himself. The mistake many with that problem make is thinking that the problem is "themselves" and they need more introspection, or more insight, or more "brain hacks." You need less of those things. What you need are goals with concrete steps that you force yourself to boringly take.

So I think your relationship will end, hopefully you'll both be strong enough and mature enough to do it without drama and the stickiness that accompanies furtive attempts at breaking up (this is your third time?) I'm sorry for you, these things are inconsolably painful for a while. But whatever happens, your future happiness is entirely related to your ability to impose your own limits on your freedom. The time has come to not be everything you want to be, but to be one thing you've wanted to be.

I may as well tell you that once you've chosen a specific goal, and begin to legitimately work towards it, you may then find a different path suits you better; but that kind of insight is only possible after activity, after doing. Less thinking, more doing.

Good luck. I hope it works out well for you.

IV.

That was what I posted at that time.

But what I did not put in that post, the thing that I deliberately withheld because I didn't want it to get lost in all the other words; because it is the most important thing, and the thing most likely to be denied-- is that this guy chose that girl on purpose, for the purpose of maintaining his ambivalent world so no concrete decisions need to be made.   Concrete=loss of potentialities= no thanks.   Math and graduating is very forward looking; it's much easier to say, "can't study now, my girlfriend needs me, she's in pain." I'd bet it makes him feel like a good person, too, all that sacrifice, just for her.

I doubt very much if he truly believed she was going to say yes. Her friends didn't think she'd say yes, apparently. The point was not really to get married, the point was to create a dramatic event upon which to focus energy and thus delay any kind of physical forward motion. By engaging in conflict that is impossible to resolve.

This is why I say he chose her to get rejected; to get jealous; to get sad over; to obsess over. And then to recruit the rest of his world into this problem. Nothing matters more than ego integrity; nothing matters more than the status quo. Do you see?

All of that is unconscious, and as soon as I say that word a specific group of people goes bananas. No one likes to think they're not in control of their own lives, that they're saddled with an Abusive Boyfriend that wants nothing to change; but if they are in control, why are they anxious all the time? Why so little progress despite resources, opportunities, and freedom? If they're in control of their own lives, why do they all dress alike?

If you're in control, why do these relationships happen to you? Isn't it more likely you chose them?

Others/the same people will take issue with my derision of introspection, because they believe it to be a Socratic ideal.   I'm not against introspection, I am against masturbation. I'm against edging. The critic wants to be able to contemplate, to go to therapy and discuss and introspect and what he will do there is talk about himself, think about himself, identify patterns in his life, things that have held him back-- and nothing will change. So then he will tell me that he has "a really good therapist, she really pushes me!"

The therapy becomes an elaborate narcissistic defense, the promise and appearance of progress while protecting an at best artificial and at worst non-existent identity. "I want to learn why I am this way." Then what? Will learning why you made those choices be what changes your choices? You're still eating junk food, aren't you? You're eating it while you're learning how bad it is.

"But... why am I this way?" That question is a narcissistic defense. It doesn't want an answer, it wants you to keep asking the question.

"I'm a good person, I just am making bad choices." Wrong. You're not a good person until you make good choices. Until then you are chaos.

And you know it.

----

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: My name is NotMichaelBay, and I just fucked your girlfriend

objet petit a my ass

The article below is a fake interview intended as parody. I did not actually interview Michael Bay. The article is written entirely by me in the spirit of humor without any malice or ill-will towards any of the people or institutions named within. In particular, in no way do the statements in the article below reflect the thoughts, opinions, beliefs or statements of the real Michael Bay. This is a work of fiction and any resemblance to actual persons living, dead, robotic, or vermiform is purely coincidental. It's a joke, people.

I'm here with NotMichaelBay, (not the) director of Transformers: Dark Of The Moon. Thank you for sitting down with me.

Yeah.

I'd like to begin by reading the opening sentence of one critic's review: "Michael Bay's "Transformers: Dark of the Moon" is a visually ugly film with an incoherent plot, wooden characters and inane dialog. It provided me with one of the more unpleasant experiences I've had at the movies." How do you respond?

By making a fourth movie. This guy sounds like a dick.

But it certainly can't be the first time you've heard similar criticisms.

Come on, you think anyone who said "the movie isn't shabby or painful, but romantic and wonderfully entertaining" about An Education can be trusted to review my movies?(1)

So you knew this was Roger Ebert? You memorize movie reviews?

I know everything. My game is tight. I'm the guy who sees you and your girlfriend at a bar, and I roll up and say, "Hi, I'm going to fuck your girlfriend" and you guys just giggle because you're too much of a pussy to tell me to fuck off. I buy you guys some drinks, tell a few jokes, next thing you know you're waiting up and I'm inside your girlfriend. Everybody wins. I give you what you want, I take what I want, and everyone hates me because it all seems so easy, which is what they want.
So they hate on me, as if they could be me but choose not to. Come on. Haters gonna hate, and haters' girlfriends gonna cheat.

But audiences have come to expect, well, perhaps not a Les Mistons or even a Rashomon, but at least a film which doesn't simply reuse existing footage from older movies and add in a new robot.

Isn't that just a sign of artistic indolence?
I'm not reuising shit. It's called 'sampling.' Like a rapper. Fuck you.

Sampling? But sampling requires you to take an existing work of art and reinterpret it for a new audience, infuse it with a new meaning. Is that your claim?

I claim I sampled the Inception soundtrack for T3.

What did you mean in doing that?

That Chris Nolan's my bitch. Fuck him and his arbitrary MacGuffins.

And there is the ubiquitous complaint that your movies are made for "15 year old boys." For example, your first shot of Carly [played by Rosie Huntington-Whiteley] has her clad in only a white men's shirt, and you offer a long, 3D tracking shot of her climbing the stairs-- on her toes, no less, and it appears you've placed the camera on the floor and are shooting upwards. Some have claimed this is merely pornographic pandering to a post-pubescent demographic.(2) How do you respond?

I need to respond to that? Seriously? I put her half naked in a movie, and you want justification?

Look, Rosie was a Victoria Secret model, right? So I set up the shot the same way she's shown in a Victoria Secret commercial, because she is a Victoria Secret model.(3)

Ah, you've deliberately made explicit Carly-the-character's semiotic connection to Rosie-the-actress, making the film's world draw on the real world. Carly the beautiful girlfriend is "in reality" Rosie, who is known to be a Victoria Secret model, which is itself another signifier, another character, and so on ad infinitum; there is no terminal woman-in-herself. Thus 'woman' is merely an image, to attract the Lacanian gaze; yet because she cannot be represented in any other way except as such an image she a priori eludes the gaze.

Exactly. And she's got a great rack.

So in doing this, you've uncovered Carly , i.e. "woman", as a partial object, the objet petit a. Women can only exist as fantasy, the cause of desire.

Her only fucking job before she met me was to get people to look at her; so I gave her that exact same job but wearing more clothes, and people are acting like I'm some sort of pervert.

But the difference is that her partial nudity is appropriate in the context of a commercial to sell lingerie. In a film, it's merely gratuitous.

She's not selling any fucking lingerie, she's selling herself and the brand and the lingerie is tagging along for the ride. What, I got to draw you a fucking picture?

Let's turn to the story. Numerous critics have decried the meaninglessness of much of the film's action. Why does the copier attack the office staff? What is the purpose of the giant Decepticon worm? There are plot holes and inconsistencies--

Woah! Slow down, wildman, those were on purpose. Look, we're all being raised by TV. Do you think as 4 year olds we really understood what the hell was going on on Batman or Scooby-Doo? You think your kids can really follow the plot of anything by Pixar? Since we've been able to enjoy movies anyway, without following the story, there's no incentive to follow it anymore. And since we have no incentive, we don't get no practice-- and now we can't follow a story, story gets distracting. Just like a porno. Fucking the most confusing movie ever made was voted to be... Vanilla Sky. WTF, you're confused by Vanilla fucking Sky? These lunatics aren't confused just by B plot, they're confused by B roll. So we cut that shit right out and replace it with something on fire.

You deliberately reduce story integrity while simultaneously enhancing the viso-auditory immediacy of the experience? Isn't that ultimately self-negating, even Dadaist?

Explosition, not exposition. That's how we do.

That seems--

In real life, too. President Bush knew we were fucked by history, right? He got there day 1, opened the Book, and was like, fuck me, this is what's really going on...? And then he looked at America and said, these fucktards couldn't find Iraq on a map of Iraq labeled 'Iraq', no way are these Raymond loving motherfuckers going to understand anything about labor costs and the inevitability of falling foreign reserve accumulation. Let's go with 'WMDs.'" A decade of historical analysis later and the deepest anyone's been able to go is, "they lied, it's really about oil!!!!!!!!!!!!!!!!!!" Jesus, what asshats. Now every time poor Obama looks over his speeches he has to say, "no good, too many syllables."

So yeah, anything that has to do with thinking or blinking is edited out in post. That's why it cost so much to make. But the original script for T3:DOTM is fucking Finnegans Wake, you can believe that shit.

No doubt it more rigorously explained the giant Decepticon worm?

Fuck you. It's looking for spice.

I'd also like to ask you about the rumor that actress Megan Fox was fired on the order of Steven Spielberg, who demanded you--

Steven didn't tell me shit, no one tells me shit, I'll kill you and witnesses, fuck that stupid morally ambivalent alien making motherfucker. I fired Megan to make a point. I replaced her in the third installment of a huge series with a complete unknown, and it didn't affect the movie at all.

Well, she wasn't a complete unknown, she was a Victoria Secret model--

You don't know anything about movies, do you? You probably believe it when actors say they do their own stunts or hate it when the paparazzi surprises them at the agreed upon time and place. Replaced Megan? I could have replaced every single one of those actors and actresses with some other supermodels, and the movie would have been better. Fuck that, I don't even need people, I could have Simoned the whole thing. I did them a favor, they need me, and when you start forgetting that you're just a motion capture device for better breast renderings, I kink your feeding tube. Good luck on your audition at Lifetime.

Perhaps a supporting character can be changed, but surely you couldn't replace Shia--

I could replace him with a fucking glass cylinder of my farts and you'd watch it. Twice, IMAX 3D and cable. You think Dr. Who and soaps are the only ones who can replace these idiots with other idiots?

But some movies open exclusively on the force of the lead actor. Julia Roberts, Will Smith--

Ha! And you're criticizing me for making shit movies? Look, there will always be a place for them, right? Voice work, what have you. "Hey, we got a bad ass talking puma that says "motherfucker" a lot. Call Sammy J." "We need a sassy, independent, girl who will immediately and happily conform to the requirements of a patriarchal society in exchange for material security. Meg Ryan that shit up."
Sure, Julia in the trailer brings the boxes to the box office, but at this point there's so much CGI used on her she may as well be a fucking Decepticon. Or did you think that's her natural skin? You don't need big name actresses anymore, you just need some mo to say "three generations of women" or a montage scene of four divorcees with wine glasses and dancing in a kitchen of Final Cut Pro vegetables. You're blaming me for the stupidity of movies? Blame women.

Your argument that women are responsible for bad movies seems untenable. With respect, your movies aren't even aimed at women.

Hey, fuckly, listen to me, my movies exist because of women, because they've driven men batshit crazy into 'man caves' and Call Of Duty XI. Did they have giant robot movies in the 1930s and 40s? No, all of those movies had dance numbers. Back when a guy could punch a dame for overcooking a chicken there was no shame in watching some fool tap dance his way through WWII. Now these bitches expect you to change a diaper and shave your balls? Fuck that. Giant robots.

Is all modern cinema then reflexively phallocentric? Does disposable art created on a background of consumerist capitalism necessitate a misogynist subtext?

I said fuck that. Giant robots.

Do you truly believe that modern males feel emasculated by the rise of the female underclass?

No guy feels emasculated by women, at all. He thinks men in general are emasculated by women, but not himself. His rage is that since women have emasculated everyone else, he's forced to sublimate his own urges to fit into this emasculated society. So he's holding two contradictory ideas: that he himself is man enough to resist the emasculization that women impose on men; and simultaneously justify why he isn't the man he thinks he should be. In essence, he's created the perfect explanation for why he is, and rationalization for becoming, Nietzsche's Last Man.

So it's a failure not of assimilating a feminine power, but a strictly narcissistic defense of the ego.
It's also why you're going to see more movies where the action hero is a little girl. They represent the last attempt at staving off death. First you're going to be a superhero; then you'll meet a superhero; and finally your kid will be the superhero. And mom has to die in order for the Electra Complex to be fully realized.(4)
That was-- remarkably insightful...

Bottom line this shit up: everyone loves jive talking robots.

I sense that perhaps it's more than misogynist, perhaps it goes to the level of minsanthropy, even nihilism? You've offered a critique of the inevitability of art but the irrelevance of the artist.

Hey, what the fuck do you think I am? I am a great artiste, with a capital T,I,T,S,A,R,E,G,R,E,A,T. You don't think I could make "good" movies? I went to school at Wesleyan, I studied under Basinger. I can make anything go triple platinum, anything. I could make just the poster of a movie and it would win every Oscar in every category every year, fuck James Cameron and his stupid boat. Do you know what would happen to this planet if I made a porno? That would be it, done, everyone in the world would drown in their own ejaculate. We'd have to Noah's Ark two of everything and start civilization over.

Then why don't you make more serious movies, more enduring films? Why do you choose to make--

Because Obama pays me not to, like a subsidies program, because otherwise everyone else would go out of business and California would have to be returned to the Pacific or sold to the Chinese.

The movie is called The Transformers, ok?-- as in I transform you from unemployed to employed. I'm a motherfucking jobs program, I'm like the New Big Deal. It's a movie about giant robots, what the fuck do I needs peoples fo? Because: Obama needs to cut the space program, so I put Buzz Aldrin in a movie. I gets him paids. John Malkovich is a versatile actor, an artist, but he's not getting paid shit for any of his crap. He calls me up-- boom. Payday. John Turturro's been in 20 movies since The Big Lebowski. Name one. Can't. SAG calls me up, boom, his kids go to college. Now he can make shit like Somewhere Tonight and tell everyone he's not an actor for the money.

No more Matrix? Boom, Hugo Weaving is Megatron. Leonard Nimoy needs new dentures? Boom, chewing apples like a motherfucking horse, vitamins and fiber.

I own Hollywood, I control destinies, there's nothing I can't do on film. Not only did I give Frances McDormand a job, I got that bitch to look almost sexual. In 3D. Do you know anyone else who can do that? You see Fargo? Did you want to fuck her in Fargo? No. But I guarantee you someone in America saw T3 and jerked off to Frances. Fuck all y'all.

So the future of cinema comes full circle, back away from the cult of the actor to the primacy of the director. You see a future where even mass consumption cinema follows the director; we'll choose to see "Michael Bay's new movie" not "Shia LaBeouf's new movie." This had previously been the privilege of director-artists-- Woody Allen or Hitchcock come to mind-- but who did not enjoy mass appeal.

If someone goes to see Transformers because it's "Shia Labeouf's new movie" and that person is not Shia Labeouf I'll slit my wrists.

Thank you for your time and candor.

This parody is free speech protected by the First Amendment. No videos are hosted on this site and remain the property of their original owners. The images, stills, and video clips are the property of their original owners and their use herein is permissible under the fair use provisions of U.S. copyright law and under the corresponding legal theories of copyright and intellectual property law around the world. Again, I didn't actually interview Michael Bay, but I'd love to.

---

1. A much better review of An Education

2.

3.

4. The next phase in the evolution of action movies

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===== ====== ===== The Last Psychiatrist: Narcissism Out Of The DSM-- And Into The Open

nothing to be said

Jay Mohr, popular comic and actor, did a phone-in to the Opie & Anthony radio show and told this story (I recite from memory):

So I'm shooting Hereafter, and there's a scene where I walk up these flights of stairs, I fumble for my keys and my next door neighbor is supposed to hand me my mail, and it's a letter from Matt Damon and blah blah blah.

So all she has to do is hand me the letter and say, "here's your mail." But she's some San Francisco wannabe actress, and she's decided she's going to get her Oscar on this movie. So she comes over, all dramatic, and she says, "so, ummmm, hi.... You want your mail?... Looks like you got a letter here...." And she hands it to me, but then she pulls it back at the last second, because she wants to be a cunt, and I reach for it, she pulls it out of my hand again. So finally I just grab it, and she says, "well, enjoy your mail."

So Clint Eastwood (the director) is down at the bottom of these three flights of stairs watching all this on the monitors, and you hear him say, "goddamn it!"-- he doesn't even yell cut-- and he starts coming up the stairs, he's like 9000 year sold, coming up, puffing, really slowly. Finally he gets up to the top and he looks at her and he says, "honey, I can't begin to tell you how much this movie isn't about you. If I could have hired just your goddamn arm, I would have."
II.

You may have heard the news: "Narcissism is being removed form the DSM."

Narcissistic personality disorder, characterized by an inflated sense of self-importance and the need for constant attention, has been eliminated from the upcoming manual of mental disorders, which psychiatrists use to diagnose mental illness.
That sentence is technically accurate. What's missing, however, is that it would be replaced by something else, a more wordy, symptom cluster description of a personality disorder. You can still "diagnose" someone with narcissistic traits.

However, on the face of it, people are understandably freaked out:

One of the sharpest critics of the DSM committee on personality disorders is a Harvard psychiatrist, Dr. John Gunderson, an old lion in the field of personality disorders and the person who led the personality disorders committee for the current manual.
Asked what he thought about the elimination of narcissistic personality disorder, he said it showed how "unenlightened" the personality disorders committee is.
"They have little appreciation for the damage they could be doing." He said the diagnosis is important in terms of organizing and planning treatment.
Since he doesn't get Pharma money, there's no need to disclose his megalodon sized bias: his whole career is about measurement tools for narcissism.

And so if you're thinking that the craziness is that psychiatry is the doing away with the concept of narcissism you have fully missed the point: the issue isn't whether narcissism exists or not, the issue is who gets to decide if narcissism exists or not.

You break it, you bought it.

III.

Here's a metaphor. When The Oscars, defying all logic and sanity, choose Sandra Bullock as best actress-- a woman who Gwyneth Paltrow (Shakespeare In Love) once used as an example of the kind of actress she didn't ever want to be (Demolition Man-- anyone see the irony?) the strength of that choice isn't that her performance in The Blind Side is even good but that I, me, a guy who watches movies, believes that The Oscars are nuts for choosing her: they have tricked me into thinking that their decision has any relevance.

I realize it matters to the actors' future salaries and sales and blah blah, but these annual terrible picks reinforce to me that they should have picked something else. But why should they have? As a reasonably educated person I recognize that people have individual tastes; but that there are some things that make a work of art better or worse; but neither of those things are the purview of The Oscars-- they only make me think it's their domain. In other words, who cares what they think? But while I have no problem dismissing the relevancy of the Super Bowl victor, it still infuriates me that the Oscar goes to X, and that's because they've beat me. I know they don't have any say about what is good. And yet I'm furious, every single year.

IV.

You want a historical example, here you go. No one gets diagnosed with obsessional neurosis anymore. People do, however, get called obsessional and neurotic by regular people.

What happened is that a term that highly educated and philosophically precise people used all the time was turned into a vernacular label; and the power of "diagnosis"-- read: labeling-- seized by the new emperors of psychiatry with a different paradigm.

The person in the chair is still recognized to have a pathology: but one group is dismissed by the other group as being mean, pejorative and unrigorous: "we don't call it that, that has no construct validity, it's better described as this."

Never mind that the new terms have no more validity than the old terms, and are equally invented. That's not the point, diagnosing the patient isn't really the point, the point is that the DSM is the authority. They've made it that the burden of proof of disagreement is on you, not them. They gain the credibility not by improving the diagnosis, but merely by altering it. And so you all say, "well, I think they're wrong, but they must have had some scientific reason that I don't fully understand..."

And you're stuck. You're left suspecting that there is something really, really wrong, but since it's not bipolar and it's not a unicorn you're left wondering if you're not just a prejudiced ass. Worse, the only one you can turn to for "support" is Freud, et al, which immediately gets you labeled as a nut.

Yet you can't help but see it-- so you tentatively try to dress it up in the least disparaging way you can, and turn to psychiatry for a little help, but:

"Well, we all know there's no such thing as hysterical neurosis. Allow me to offer an equally arbitrary but nonetheless reliable construct that puts all the power of labeling in our hands."

Wait, that's not what I was going for...

V.

Let's go back to that telling scene in Hereafter. To the extent one can make a judgment on a single anecdote, let's agree that at that moment the actress was behaving narcissistically. Psychiatry, however, would not have a quick way of discussing this (and, truthfully, it didn't a year ago either.) But by not having a useful description of it, that behavior is no longer psychiatry's problem.

Added bonus: it's yours.

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===== ====== ===== The Last Psychiatrist: Narcissism Run Rampant

we'll have the sex so you don't have to

Is narcissism on the rise in college kids?

According to Prof. Jean Twenge at San Diego State, it is; to Prof. Chris Ferguson in The Chronicle of Higher Education, it is not:

The evidence just isn't there for an epidemic of narcissism or anything else. Social scientists would do well to exercise a degree of caution when interpreting data. Just like with the little boy who cries wolf, people are bound to notice too many phantom epidemics. The price to be paid is the credibility of social science itself.

At the core is the study by Twnege finding that college kids are becoming more narcissistic over the years.

The Chronicle disagrees, taking the perspective that data is conflicting, and anyway "epidemics" and "crises" are often fads of the social sciences.

So Twenge says it's on the rise in college kids and Ferguson says it's not. My question is, who cares? Seriously, so what? I admit it's annoying though enlightening to be in a bar near them, but otherwise, does it matter? The problem isn't the college kids, the problem is the adults.

II.

Take a developmental perspective.

If you follow that narcissism is more appropriate in adolescence than in middle age, then it may just be that adolescence has been extended into your late 20s, i.e. that we really should be comparing the narcissism of college kids in 2010 to the narcissism of 10th grades in the 80s. This isn't a slander/libel, it's to put the social context out front. If you adults-- media, parents, givernment, colleges, banks-- created a society that promotes lingering adolescences, you can hardly blame college kids for lingering. Right? When Vanderbilt University spent $150M to create a walled garden for their freshman nymphs and satyrs, did you expect them to instead join the Marine Corps? If I went to Vanderbilt now, you know what would happen? I'd be pregnant. Yeah. Figure that one out.

you want us to grow up... why?

I don't want kids to be narcissists, of course, but I simply don't know if what Twenge detected is pathological narcissism, a relatively stable trait over time, or developmentally appropriate though tremendously expensive adolescent narcissism.

It is completely useless to talk about the narcissism of kids without first yelling about why they have whatever level of narcissism they do have: adults. You made them this way. Honestly, I doubt if you (an individual parent) could have done anything differently, the entire structure was built for that purpose-- kids have disposable income so let's build a giant marketing network around that, along with TV and movies and people you want to be like, and probably adults will want to be part of the youth crowd because being an adult blows so you know what to do for them: create a show called Friends, then replace with Sex and The City, then Cashmere Mafia, which are all the same show but less funny but either way they will buy shoes.

"They're going to have to grow up eventually!" First, I hear contempt in your voice, like you can't wait till they have to suffer. That's narcissism. Get that out of you, why should you be happy that they're going to suffer? Do you see how you take their lives and reduce it to how it impacts yours? Fix that, forget about them. It's a miserable way to live, your own successes will never be enough to make you happy. Ask Mel Gibson.

But here's an alternative response: really? do they have to grow up? Haven't you constructed a society where you can credit your way to a simulacra of branded prosperity for the next few decades? Healthcare, social security, unemployment and extremely cheap food? I know, I heard it to, the Dutch have it better in Sweden.

What we should be asking is not how the kids got this way, but how the 50 year olds got this way. It's the same answer.

III.

One thing you should know about the study done by Twenge: it uses the NPI as a measure. The Narcissistic Personality Inventory is a valid and reliable measure of the kind of narcissism a layman thinks of when he thinks of narcissism: someone on The Bachelor. Extraverted, grandiose, vain, overconfident, exhibitionistic.

Here's the guy the NPI does not detect. Nor the guy who kills his family, nor the suffering 40 year old man who can't seem to get a date despite how much time he spends learning how women think and what tricks to use.

IV.

If you're on a desert island and you're a narcissist, it doesn't matter. It only matters as it affects other people.

Were a narcissism epidemic truly striking the United States, we ought to ===== ====== ===== The Last Psychiatrist: Narcissism Up In College Students; The Goal Is To Keep Them In Puberty, Part 3
Hold on-- not in all college students, and not all in college students, and not in all college students in all times...

From the Journal of Personality, Egos Inflating Over Time: A cross-temporal meta-analysis of the Narcissistic Personality Inventory-- which the blogger from fashion-incubator sent to me a year ago, before it was even published:

Meta-analysis of studies in which college kids over the decades were given the Narcissistic Personality Inventory, it found that narcissism is on the rise.

The authors offer a helpful analogy: if the average student in the 1980s scored in the 50th percentile for narcissism, then the average 2006 college student scored in the 65th percentile-- 2/3 of 2006 college kids are above the 1980 mean for narcissism.

Some interesting findings:

the college students scored the same level of narcissism as a study of 200 celebrities. (more on that later.)

Women's scores rose more rapidly than men's. In 1992 the SD between men and women was 0.45 (men higher); in 2006 it was 0.15.

II.

But not everyone agrees.

Another group, disbelieving the above study (apparently, even before it had been published), investigates their own 25000+ gigantic sample of UC Davis and UC Berkeley students and found that scores on the NPI, and their own measures of narcissism, were relatively stable. I should mention here that the NPI measures more of the extroverted, "self-enhancing" kind of narcissism, because that's important for understanding why this result is probably wrong: 40% of UC students are Asian, vs. 6% in the rest of American colleges. I hope this doesn't require any explanation.

III.

What do Twenge et al say is the consequence of all this narcissism?

"A trend among college students toward "hooking up" rather than...relationships;"
81% of students thought " getting rich was among their generations most important goals" (rich is the new porn);
51% said it was getting famous.

They have more trouble explaining the other... associations: crime is down; volunteerism is up. But to me, these are hardly inconsistent with narcissism. Narcissism doesn't mean you're bad, just that you think you're the main character in your own movie. Maybe that movie is about a woman who works for a non-profit but manages to date the President.

But the authors can't explain why narcissism is on the rise, and they point to the usual suspects:

Schools and media: "Children in some preschools sing a song with the lyrics, "I am special/I am special/Look at me ...", and many television shows for children emphasize positive self-feelings and specialness."
Grade inflation: "In 1980, only 27% of college freshmen reported earning an A average in high school, but by 2004 almost half (48%) [did.] However, the amount of studying has actually declined, as has performance on tests like the SAT. "
Technology: "Devices such as iPods and Tivo allow people to listen to music and watch television in their own individual ways, and websites such as MySpace and YouTube (whose slogan is "Broadcast yourself") permit self-promotion far beyond that allowed by traditional media. These trends motivated Time magazine to declare that the 2006 Person of the Year was "You," complete with a mirror on the cover."
But all that's just the consequence, not the cause.

Look at the above chart, and note the upswing after 1990. I don't know what caused those kids to be more narcissistic than the 80s kids, but I do know what happened to those 90s kids after college: they became adults. And they became the custodians of the world, and, they demanded entertainment that suited them. Music, movies, internet, technology-- all that was aimed at them, not the next group of college kids. Unfortunately for the next college kids, there was nothing else to watch. The 30 year old in 2000 wanted to watch Survivor and The Bachelor, so everyone had to watch Survivor and The Bachelor, and it's changed cognition: even kids who have never watched those shows still uses the phrase "voted off" and "immunity."

And the 35 year old in 2005 became a parent, and that parent wanted school vouchers and great healthcare, but also lower taxes and to be able to eat out at restaurants once a week. ('The kids are with my mother.") Those parents want easy credit and a bigger house.

This trend is going to continue, frankly, until we either have a major recession, war, or my generation dies.

It's funny to me, and by funny I mean I dropped all my cyanide capsules, that Allan Bloom and all the other conservative culture war guys from the 80s never bothered to follow up on the kids they thought were such idiots, such-- narcissists. Did they expect they would all die, sucked into their own skulls by the gravity as their brains went brown dwarf? Yet here they are, walking around like zombies, apathetically, pathetically, pathologically confident and cynical, ironic and happy, yet hungry and restless just the same. It's like they never aged past 25.

You can't blame todays teens and college kids for being narcissists. They're doing exactly what they were trained to do, are being told to do, what they saw done, by us.

Part 1 here.
Part 2 here.
Part 3 here. (You're reading it.)

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===== ====== ===== The Last Psychiatrist: Nature Says Scientists Use Performance Enhancing Drugs

If only it were true.

This article is about shock, and about conveying a politically correct message-- not that it's wrong to take drugs, but that it's wrong to take them if they give you an edge over someone else.

The results are (from the header:)

Poll: Scientists Use Brain-Boosting Drugs

Survey of Magazine's Readers Shows 1 in 5 Take Mental-Performance-Enhancing Drugs

and from the article:

Scientists from all over the world participated in the poll, but 70% of respondents said they were from the U.S.

The most popular drug was Ritalin, used by 62% of responders. Provigil was the drug of choice for 44% of those polled -- suggesting that many of the users take more than one drug.

First, 1 in 5 is actually pretty small. I'm surprised at how small it is.

Second, it's misleading. The readership of Nature isn't scientists, it's college kids and grad students. If you read the article, you'll observe that that over half of the respondents were under 35. While I'm sure they are all doing impressive work, they aren't the stereotype invoked by the title "Scientists Use Brain-Boosting Drugs."

But third, and to the point: the article simultaneously presumes, and reinforces, the idea that scientists are using these drugs improperly-- i.e. that using them on 9 year old kids with "ADHD" is their proper use. You would think that one of the scientitians down at Nature might have observed how preposterous that is.

If anyone can tell me why it is more logical, medical, ethical, efficacious, or safe to force it on a kid who scores high on a reliable but totally invalid ADHD checklist; but less so for a "scientist" with considerably more insight into his own condition-- and, by the way, the autonomy to decide for himself-- I'm listening.

That aside, let me ask a different question: why not encourage the use of the drugs? Beyond safety issues, is it just that we're worried about unfair advantage in science? That's the debate in sports, that it doesn't allow for a level playing field. You want a fair competition.

But why would you care about that in science? I mean, if it takes 800mg of Provigil a day to find the cure to cancer a month earlier, well...?

So there's the academic scam: it isn't about the cure. It actually is a competition. Different labs vying not for the cure per se, but for more funding, promotions, jobs, publications. If one lab is doing coke out of 96 well microplates, another lab might feel pressure to smoke crack out of Eppendorfs, I guess.

Though at one point in my life I even resorted to using chocolate covered espresso beans in a pharmaceutical capacity, 10 tabs QID, I'm not endorsing the use of such drugs in anyone; but I hope everyone can see that the division between proper and improper use completely invented, and upheld by those who have much to lose should that division be eliminated.

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===== ====== ===== The Last Psychiatrist: Nature Weighs in On What Is True

and turn out to be wrong.

There's been something of a controversy raging over the best place to get accurate information.

Specifically, there's a free, user-written encyclopedia called wikipedia at http://www.wikipedia.org that competes with the
Encyclopedia Britannica. The idea is that anyone who uses wikipedia can edit any story. So if you happen to be reading an article that has an error in it (for example, if it says the Constitution was ratified in 1798) you can correct it with a few clicks (e.g. you change it to 1789). Aside from controversial topics (where articles are edited constantly to favor one
opinion or the other), the "hard facts" articles on science, culture or history are fairly decent. Or so they seem at first glance.

The controversy is this: Britannica's editor in chief went on record (in a newspaper article I can't find) stating that Britannica is a better, more reliable source of "knowledge" because it's a closed controlled editing environment, where articles are researched, edited, and reviewed internally by academics who are experts in their respective fields.

Wikipedia responded saying it doesn't need all that editorial oversight because any error in an article is corrected relatively quickly by an expert in the field.

The essence of the argument is "top-down" (Britannica) vs. grass-roots/bottom-up (wikipedia), or, to put it more succintly, does the existence of a gatekeeper for knowledge improve the quality, accuracy, and veracity of knowledge?

The debate matters for two reasons: (1) at some point people have to agree on the basic facts of whatever they are talking about, and (2) there needs to be a place where you can find the core true facts about any subject.

So anyway, the medical journal Nature decided to compare the two sources of knowledge:

http://www.nature.com/news/2005/051212/full/438900a.html

Now you may ask what the hell business is it of Nature's (a quasi-medical journal) to do this (review the accuracy of encyclopedias), but that's my point and I'll get to that in a second.

Anyway, surprise surprise, Nature says that in the case of science articles, wikipedia is better. This was not unexpected - wikipedia claimed all along that it amounted to enabling peer-review of its articles by readers, and Nature, of course, is all about peer-review.

Britannica responded, finding errors in Nature's methodology (warning: pdf ahead, but it's worth reading if you think for a second Nature should be trusted to do anything):

http://corporate.britannica.com/britannica_nature_response.pdf

concluding that the study was bogus, and that Britannica had far fewer errors and omissions than Nature claimed.

What interests me here is not the accuracy of Wikipedia vs. Britannica, but why Nature feels it is in any position to examine this.

Here is Nature's response to Britannica's criticisms:

http://www.nature.com/nature/journal/v440/n7084/full/440582b.html

Here's the line to focus on:

"Britannica complains that we did not check the errors that our reviewers identified...but there is a more important point to make. Our reviewers may have made some mistakes — we have been open about our methodology and never claimed otherwise — but the entries they reviewed were blinded: they did not know which entry came from Wikipedia and which from Britannica."

For the record, Nature says this is how the test was
conducted:

"Each pair of entries was sent to a relevant expert
for peer review. The reviewers, who were not told
which article came from which encyclopaedia, were
asked to look for three types of inaccuracy: factual
errors, critical omissions and misleading statements. 42 useable reviews were returned."

And this, my scientician friends, is why medicine isn't a science. Nature is saying that its methodology is sound because the entries they reviewed were blinded - BUT WHO ARE THE PEER REVIEWING EXPERTS, WHO SELECTED THE ENTRIES, AND ACCORDING TO WHAT CRITERIA?

You cannot excerpt an article describing something and then test the excerpt for omissions. Furthermore, the excerpting is not blinded, and the person excerpting things may have a different opinion of what can be safely left out than the person doing the review.

Nature's mistake is assuming that the expert is always right. If the expert disagrees with Britannica, then Britannica is wrong. You should be able to test the accuracy of an entire encyclopedia article *by giving it to multiple experts*. Not the other way around, multiple articles to one expert. The hypothesis is "do experts think the article is correct", and you test it by find the percentage of experts that think it is/isn't.

What is truly ironic is that while Nature likes to hold itself out as an open source for medical knowledge (and thus more like Wikipedia), it is in fact a gatekeeper of knowledge like Britannica. When Nature publishes an article, the belief of the scientific community is that the article is correct *because it's in Nature*. But Nature is the journal of statistical regression sciences - medicine, global warming, etc., i.e. disciplines where there is no right answer or it's impossible to know the right answer because you are observing only a small percentage of all the variables being affected. It tests associations, not causality.

Keep this in mind when a journal like Nature also makes policy proclamations ("global warming needs to be stopped") or creates artificial hierarchies by its coverage (substantially more articles on HIV than malaria, so HIV becomes more "important" than malaria, etc.)

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===== ====== ===== The Last Psychiatrist: Neither Is This Is A Narcissistic Injury

I have another unrelated post coming, but a quick word on insults vs. narcissistic injuries, and why this distinction is so important.
Narcissistic injuries have nothing to do with sadness. They are always and only about rage.
The narcissist says, "I exist." A narcissistic injury is you showing him that he does not exist in your life. Kicking him in the teeth and telling him he is a jerk is not a narcisstic injury-- because he must therefore exist.
Let's say I'm a narcissist, and you send me a 10 page letter explaining why I suck, I'm a jerk, I'm an idiot; you attack my credibility, my intelligence; and you even provide evidence for all of this, college transcripts, records from the Peters Institute, you criticize my penis size, using affidavits from past and future girlfriends-- all of this hurts me, but it is not a narcissistic injury.
A narcissistic injury would be this: I expect you to write such a letter, and you don't bother.
This is most easily seen in the failing marriage of a narcissist.
The reason it's important is because the reaction of the narcissist to either "insult" is different. In the first example, he will be sad and hurt, but he will yell back, insult you, or cry and beg forgiveness or mercy--he will respond-- maintain the relationship.   He'll say and do outrageous things that he knows will cause you to respond again, to prolong your connections, even if they cause him misery. He doesn't care that it makes you and him miserable-- he cares only that there is a you and him.
But in the latter case where you ignore him, humiliate him-- an actual narcissisitic injury-- he will want to kill you.

----
And before everyone flames me, I am not trying to give a scientific explanation of the pathogenesis of narcissism. This is simply one man's opinion of how we can specify what it is, and what it may predict, past or future. Nor am I suggesting this isn't "treatable"-- anyone can change. It may not be easy, but it is always possible.
And I also do not mean to imply that all narcissists will kill everyone who injures them. The point is rage. They may never act on it, or they may break a window, or attempt suicide, etc.

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===== ====== ===== The Last Psychiatrist: No Bias Anywhere Here: The Future Of Bias
If Carrie at the end of Carrie and the melting Nazi guy at the end of Raiders had a kid, and then set him on fire, that's what I look like right now.

A study on "prior authorization."

Some drugs are covered by insurance, some are not; insurance companies have medication formularies. e.g. Zoloft may be covered, Lexapro might not be. If a doctor wants to use Lexapro, he has to fill out a prior authorization form detailing his reasons for choosing the non-formulary drug. The request can be allowed or denied. The point of it is simply to-- nudge-- the doctor towards the formulary drug.

BACKGROUND: Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes...CONCLUSIONS: Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users.

What do the authors want to be true?

I.

First, let me explain why the conclusions of this study, (prior authorization leads to a "substantial public health benefit and cost savings" (as the editor summarized in his editorial entitled, "The Change We Need In Healthcare" (yeah, that's what he called it; soon we'll see "Dopamine Blockers in Schizophrenia: Mission Accomplished"))) are completely misleading.

Despite what you and logic might think, insurance companies and Medicaid do not pick their formulary based on what is most efficacious, or even what is cheapest. They put things on based on the deal they strike with the drug companies. By "deal" I mean "payoff." By "payoff," I mean "kickback," in a mechanism so needlessly complicated it can only be on purpose. Many "non-preferred agents" are cheaper/better/safer than the "preferred agent."

If we move to a single payer model (BTW: will never happen, ever, I'll explain why) that payer may be able to negotiate lower prices overall, but it will be because of the "deals" and not because of judicious evaluation of safety or efficacy. If the FDA can't competently evaluate safety and efficacy, do you think Medicare can, and still account for the third variable of cost? And what would we need doctors for?

And think about the way the clincial decision is made. These deals occur outside and before the doctor-patient interaction. The doctor has no choice but to use the products available to him. He has the option of going off-formulary, but it is so difficult that it is impractical. In other words, Pharma and the insurance company have colluded to control the market. You didn't like it when Microsoft did it. Isn't this the definition of racketeering?

II.

What do the authors want to be true?

I know what a "Department of Ambulatory Care and Prevention" is. But do you know what a "Harvard Pilgrim Health Care" is?

Oh, they're the same thing.

III.

Imagine if Harvard's department of surgery was sponsored by Intuitive Surgical; or their psychiatry department was sponsored by Pfizer. Imagine those pairs then went on to make policy decisions, like teaching residents that the DaVinci system is first choice for surgeries; or teaching med students that Zoloft is first line for depression. Those would seem like conflict of interests that would never happen in today's anti-bias climate. But there you go.

You might not think this is as bad as Pfizer running the Harvard Psychiatry, but it's actually much worse, because there are competing alternatives to Pfizer but there are no alternatives to insurance-- especially if we get a single payer.

I'd like to point out that Harvard has banned drug pens from the school because that influences prescribing.

What are the chances that an academic at Harvard on the brink of becoming Associate Professor is ever going to "discover" that preferred drug lists aren't a good idea?

If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca.    The next unholy alliance is between academic medicine and insurers/providers. The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare.

Academics won't be scrambling to get Pharma grants; they'll be looking for Aetna grants. And ten years from now, when we finally wake up, we'll be asking how we let insurance companies and government ever get so close to medical education, how we let them "corrupt" our residents.

While we were distracted by Carlat for repenting his Big Pharma ways, no one noticed the answer:

The answer is: some spots opened up, and they were available.

===== ====== ===== The Last Psychiatrist: "Nobody will understand what went on in this house to drive my dad to this level of insanity"

let me take a shot

An article in Marie Claire making the rounds via Jezebel and wherever binary political judgments are favored.
This is a version:

Around the sprawling, sunbaked campus of Dysart High School in El Mirage, Arizona, not many people knew about the double life of a pretty, dark-haired girl...
At school, she was known as a fun-loving student who made friends easily. She played tennis in a T-shirt emblazoned with the school mascot -- a baby demon in a diaper. She liked to watch Heroes and eat at Chipotle. Sometimes she talked in a goofy Keanu Reeves voice. She wore dark jeans, jeweled sandals, and flowy tops from Forever 21. She texted constantly and called her friends "dude." In other words, she was an American girl much like any other.
But at home, [she] inhabited a darker world.
I'll fast forward to the end: her father runs her and her 43 year old female friend over with his Jeep in the parking lot of a Mexican restaurant. He then swings the Jeep around for a second pass. When he's done, he flees to Mexico.

No need to speculate on Mexican illegals; lesbians, drugs or mental illness, or other go-to media explanations. In this case, everything you need is right there in the title: An American Honor Killing. Yeah, they're Iraqi.

II.
The fact that the Almaleki family is from Iraq is integral, by which I mean incidental, to the story.

But honor killings in America are a chilling new trend. In Texas, teen sisters Amina and Sarah Said were shot dead in 2008, allegedly by their father because they had boyfriends...25-year-old Sandeela Kanwal was allegedly strangled by her father for wanting to leave an arranged marriage... Aasiya Hassan, 37, was murdered in perhaps the most gruesome way imaginable: She was beheaded [by her husband]... for reportedly seeking a divorce. And this past spring, 19-year-old Tawana Thompson's husband gunned her down in Illinois, reportedly following arguments about her American-style clothing.
None of the people in that paragraph are Iraqi. The Saids are Egyptian. Kanwal and Hassan are Pakistani; Thompson's husband was black and a convicted drug dealer who killed her, their 7 month old and two nieces, 3 and 16, apparently on the advice of voices in his head. If you can spot what they have in common, call me.
"They're all Muslim, dummy." Oh, the religion takes precedence over everything. So that's why Iraq and Iran get along so well.

III.

No, I didn't turn Left at the internet, I am not gunning for a spot in The Chronicle of Higher Education [sic.] Of course it has to do with their being Muslim, but not in the easy way the article wants it to be.
First Law of Media: offer the reader the opportunity to debate the conclusions, but force him to accept the form of the argument.
You get to argue about whether Islam allows honor killings: "religion of peace!" "No, religion of hatred!" or whether this is generalizable to all Muslims, as long as you accept their premise that she did something that deeply offended her father and Islam. Put it in the article with an apologetic cop-out:

Although honor crimes aren't officially sanctioned by Islam, they're associated with predominantly Muslim countries
They're not associated with Muslim countries, that's what they're called when they are associated with Muslim countries. When they're associated with rich black guys, they're called OJ Simpson.

III.

An aside: if you're going to argue about something solely on the basis of your personal prejudices, at least pick the side whose consequences support your worldview. So a practical reason why you don't want this to have anything to do with religion is that it is very easy to make the explanation for a murder become the excuse for it as well.

Imagine that by calling this an honor killing, you make it impossible to give him the death penalty because the defense can argue that this is really an anti-Muslim political show trial. I realize that sounds far fetched.

[Arizona Republic:] "An open process provides some level of assurance that there is no appearance that a Christian is seeking to execute a Muslim for racial, political, religious or cultural beliefs," (public defender) Little wrote, referring to [prosecutor] Andrew Thomas' Christian faith.

The debate stopped there. On Tuesday, [prosecutors] filed a motion indicating prosecutors would not seek the death penalty... a spokesman for the County Attorney's Office declined to comment on the decision.
In law, like in anything else, you get what you pay for.

IV.

The problem with the "Muslim honor killing because she turned her back on traditional values and wanted to be more American" logic is that she was already an American, Americanized, eyeballs deep in Americana well before he killed her. Nothing in the article suggests that her life was ruled by a strict Muslim code. The father recently became an American citizen; the kids went to regular schools, texted, MySpaced, listened to Oasis (why?), worked at Chipotle. This is her brother's profile on Facebook:

I guess it's possible an Iraqi "fundamentalist" could wear U.S. Army camo pants because Sharia law doesn't preclude irony, but a more likely reason is he isn't a fundamentalist. Just guessing.
But the article insists that this is about straying from her expected Muslim path. e.g., in her senior year, 2007:

Noor would hint at threats from her father to send her back to Iraq (where, he said, she would "learn to be a good girl"), but no one really took him seriously.... Friends say her father had had enough of Noor asserting her independence and talking to American guys, so he and her mother tricked her into traveling to Iraq, telling her they needed to visit a sick relative. Only upon arrival did Noor learn of the real reason for their trip: to marry her off.
This is a typical paragraph from the article, all which try to paint the picture that her Dad wanted her to be a certain Muslim way, she didn't, and so he killed her.
...by May 2008, the family was in full crisis. Noor's father had found a photo of her with male friends on MySpace, and he didn't like it. The situation became so heated that she started talking about moving out. One day, when Noor took the family car to visit a cousin, her father reported it stolen. When she learned what he'd done, she left the car on the side of the road and walked away. According to police records, her father wanted to file criminal charges against Noor to "teach her a lesson," telling police she was "disgracing the family" and that it didn't "look good" that she was moving out. Eventually she did move in with a friend. But after repeated run-ins with her father, and after learning that her mother was casting "spells" on her host family, she gave up and returned home.

...And in the spring of 2009, Noor got her own apartment... The next few weeks brought happier times... To pay the rent, Noor worked at a local Chipotle; she'd also begun attending Glendale Community College.

When Noor's parents learned where she was working, they started showing up and insisting that she move back home, so she got a job... as a hostess at Applebee's. They turned up there too, leaving her no choice but to abandon that job as well. With no source of income, she was forced to return home once more.
There is nothing in those paragraphs that would explain what would enrage the father so much as to want to kill her; or, put differently, all of these things already happened and he didn't try to murder her. What here requires him to kill her?
V.
If you need cognitive anchor for interpreting this article, here it is: people routinely scrutinize every word of a New York or Washington Times article for bias, yet an article in Marie Claire is taken to be the whole story.
VI.
The moment you say, "wait a second, this is for Marie Claire readers?" you start to see the sentences differently. They are phrased in such matter of fact, Marie Claire simplicity that you miss that they are asinine. You buy into them immediately.
The final blowup came that summer. In June 2009, longtime family friend Amal Khalaf awoke to find Noor sleeping in the family's van, parked in the driveway. Noor said her parents had hit her; Amal, a mother of four, took her in. To Noor's family, this was the ultimate indignity: Their daughter had chosen to live with another Iraqi family instead of her own.
Why would living with another Iraqi family be the ultimate indignity? I'm not even clear why it would be an indignity at all, but the ultimate? Worse than moving in with a Jewish boyfriend? But on passive reading "living with a different Iraqi family" somehow makes sense and you stop there. You don't think to ask if there was not something else that was enraging about it, you go along with the Marie Claire, "she offended her father and his values of Islam" theory.    And there was something else but the article barely mentions it, let alone explores the intricacies of it. 6 pages, 5000 words long, and this is all they say:

It's unclear whether a wedding actually took place. Some friends say she only attended an engagement ceremony; others tell me they believe she did get married, albeit against her will. Still others say Noor was given a choice of five brothers, but her parents didn't like the one she chose, so the wedding was called off. Noor's parents, in police documents, maintain that a marriage did, in fact, occur. Whatever the case, Noor returned to Arizona a few months later without a husband, and moved back in with her family. She missed her younger siblings, friends say, and her parents needed help caring for them.

Why didn't he kill her when she when she first started talking to boys? Why didn't he kill her when she started wearing American clothes at age 4?
The answer is: they lived in America for 16 years, where that behavior doesn't shame him. He may not like it, but there is no one who would look down on him here. Shame is exposure, and as long as all these behaviors stay in Phoenix, no one knows what "s/he's" done.
It all fell apart because he sent her to Iraq. When he committed to the all-in, hail mary plan of sending his daughter to Iraq to get married, where she either rejected five men as unsuitable(!) or worse, got married to one of them and then went on cavorting with men in the U.S. (!!!!)...
... never mind what Allah thinks, now everyone in Iraq knows what kind of a man he is.

VII.
The article doesn't mention any such communications; it barely references the marriage. The article wants it to be about a woman finding herself, and struggling to separate from her father. In other words, it's a domestic abuse story that they package as a honor killing story.
If you are an immigrant or of immigrant parents then you'll know: that man was in daily communication with people in Iraq thanks to the stupid internet and mobiles. He was better connected to some Iraqi 3rd uncle than he was to his next door neighbor. And, especially after his daughter returned, those communications were torture. Explaining what went wrong with his daughter, why she wasn't being honorable, why he couldn't control her, how it was his wife's fault, his sons' faults-- in short, constantly on the defensive about how he couldn't keep his house in order, constantly subject to the criticisms and patronizing responses of an extended family that is so much a part of his identity and so little a part of hers.
Not only was he ashamed, but worse, she was not ashamed at all. She didn't even care what they thought!   How could this animal not understand that how relatives In Iraq she never met viewed her was far more important than any internal sense of self-worth?
And more practically, how do you explain to her "husband" and his family, back in Iraq, that his daughter is an adulteress?
That's got to be frustrating.

VIII.

This is what her brother wrote on Facebook:

What grabs the most attention from this situation is the fact that this is a Middle Eastern family. This happens quite often in the U.S., parent(s) hurting or killing their child(ren). The "Freedom of Speech" given to you guys, have made you all senseless, arrogant, mindless pricks. Everyone just talks, and has NO IDEA what they're talking about. The media, has drawn this image that Noor, RIP, was a saint, and my Dad as the Devil. Don't believe the reasoning behind this as "Too Westernized." As I have said before, me, my two younger sisters, and my three younger brothers are all "Westernized." Goes with the saying, "When in Rome, do as the Romans do." One of the biggest problems with society is that they believe whatever they see on the tube. "Too Westernized" has absolutely nothing to do with this. I'm not advocating what my Dad has done.
Another thing people don't understand is the fine line between Islam and Iraqi Culture. Iraqi Culture is misconstrued and manipulated form of Islam, that is strict on every level, and much harsh on women.
This wasn't an "Honor Killing." Media just pulls fiction out their asses. This wasn't planned.
You guys be careful what you say, that's my father you're talking about. And my father is a loving man. He loved Noor. That may raise eyebrows, and you guys are asking "Why would he do this if he loved her?" He lost his mind. Nobody deserves this, and this never should've happened. And nobody will ever understand the kind of pain my family is enduring.
As I said, the only reason this situation grabbed attention for so long is because where my family comes from. Nobody will understand what went on in this house to drive my dad to this level of insanity. You guys keep talking, your words mean nothing to me. I know what happened, I know the truth.
I lost MY sister, and am losing MY father.

IX.
Go back to the asinine statement of living with another Iraqi family being the ultimate indignity. In fact, that statement was dead on though I doubt intentionally so. If she had moved in with a Jewish boyfriend he would have been horrified and enraged, but moving in with the Iraqi Muslim family was immediately worse because-- and this is the entire point-- now everyone in Iraq is going to know. And since those people are his whole identity, he's screwed.
This is why discussions about honor killings get mired in a nonsensical theory debate about whether Islam promotes this. Even if it did, the part that requires the violence isn't some internal sense of right and wrong or "against Islam", but exposure to other human beings who will look down on them.
He doesn't care that she's Americanized or even an adulteress. He cares that people are laughing at him.
This is narcissism, and here I do not hesitate to spell it out explicitly. The obvious is that he sees her only as an extension of himself, only as she impacts his own existence and not as an independent entity. He's not better than her, she's just not a fully formed character, she's an extra.   But the more telling and scary part of the narcissism is that he thinks that by killing her, he has not merely stopped her but fixed things, erased his shame, as if it never happened. As if the people back in Iraq aren't still snickering, as if human nature and reality are subservient to the magical thinking of a man who believes a Jeep can alter what God already saw.
X.
Two constants in stories about honor killings. First, some ridiculous multicultural idiocy that honor is extremely important in such societies. The word is incorrectly used, because it means different things to West and East. Honor in a western sense something earned (even by dynasty), like a hero might have. It is internal, and while honor can be tarnished it had to be acquired first. No one would say that the Chrysler mechanic downtown is honorable, you'd just say he's a good guy, etc. But the word "honor" as it applies in "honor killings" denotes an absence of shame. Honor in that sense is a baseline, under constant threat of exposure and entirely at the discretion of everyone else.
Partly this is a function of education, partly of culture, partly of religion, but inevitably the result of shaky identity that draws its strength in the way other people see them.
The second constant is the shocked surprise that the mother or brothers helped the man get away with it (or commit it.) Why would that be surprising? If his family didn't understand, if his family would be shocked and horrified and appalled at what kind of a man would murder his own daughter, then he wouldn't be doing it. Again, he's not doing it out of internal sense of justice, he's doing it to alter how he is viewed by others around him.

XII.
I am aware of the obvious links between honor killings and Islam and I am aware of the various arguments concerning the extent to which this is cultural, tribal, religious or educational. I don't care. Practically, when you link honor killings with Islam, you make it impossible to stop them because either a) people are thrilled at the chance to attack Islam, which allows the rebuttal, "oh, you just hate Islam!" or b) people are too nervous to attack Islam, so it goes unchecked.
The first step in preventing these murders isn't targeting the potential murderer, but everyone else around him. You don't debate the cultural aspects or the nuances of Muslim theology because those are red herrings, and treading carefully on cultural sensitivities makes it that much easier for the son of a potential honor killer to say, "I don't condone it, but I understand, and you don't, you're not Muslim."
Change the form of the argument. You have to make the narcissistic honor killing a thing of even greater shame; you have to speak their language. Don't say it's wrong-- they don't care if it's wrong-- don't say it's against Allah, don't say it's tribal, don't say it's a backwards practice, none of those things matter. Say it is a sign of weakness and impotence. Keep repeating that they aren't signals that you were strong and steadfast in your faith, but signals that you so petty and unfocused such that you had to resort to this. Remind them how stupid it is to think that people are now going to forget that you're the father of a harlot and you're a cowardly murderer. No Iraqi will send his sons over to the U.S. to marry your other daughter, and for sure no American will. Keep saying that, not so the potential murderer hears it but so the kids hear it.
You might think that the American internet is the obvious place to do this, but it's not. Consider Metafilter, the online forum where no topic is too controversial for an opinion grounded in either reason or expletives.    What did the community that fears neither God nor the NSA have to say about this case?
This post was deleted for the following reason: This is awful, but we've had posts discussing honor killings in general and specific incidents before and I'm not sure what good is going to come from this one.-- [moderator]
That's why it's going to happen again.
---

Another Honor Killing, this time in Iraq.

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===== ====== ===== The Last Psychiatrist: No, Not Effexor, Too!? The Most Important Article On Psychiatry You'll Ever Read, Part II

In which Anne Neville agrees to believe pretty much anything anyone ever tells her, ever, and Richard discovers people are gullible idiots.

Go back and read Part I. Hurry.

Let's review the idea of sequential binding. A drug with affinity for multiple receptors doesn't bind to all of them simultaneously, but rather sequentially, like an aging polygamist, starting with the system for which it has the greatest affinity. Eventually, this maxes out, and it goes and adds the receptor system for which it has the second greatest affinity.
Once it has maxed out a receptor system, pushing the dose doesn't get you any more of that effect (or side effects.) You don't get less, but you don't get any more. You know what else is like that, sort of? Chlamydia.

Let's look at an SSRI, Celexa. That first S stands for selective (serotonin reuptake inhibitor.) All of its clinical effect is coming from one single receptor system; this rum fountain has only one level-- and it's not that deep. By about 20mg, you've gotten as much serotonin effect as you are going to ever get.



Certainly, by 40mg, you're all done. Do you expect the clinical difference from 10mg to 20mg to be significant? Maybe. How about 20mg to 40mg? Not so much. 40mg to 60mg? You woke me up for this?   Don't touch me.

In other words, there's only one level in Celexa's rum fountain, and it's pretty much filled by 40mg. Pushing it to 60mg ("Now, with 50% more citalopram!") gets you a whole 3% more serotonin transporter binding. Which is embarrassing. I said don't touch me. Do it again and I'm calling an adult.

So what about Effexor, the serotonin/norepinephrine reuptake inhibitor, invented at Wyeth Labs by Kirsten Dunst, aka Vitamin C?

From the American Journal of Psychiatry study:
la, la, la , la , la, la ,la ,la ,la ,la
la ,la ,la,la, la,la
yeah, yeah, yeah,
la, la, la, la, la, la, [repeat x 36]
we will still be friends forever [sic]

Which is exactly the point. You don't get both S and N at all doses, it is, again, sequential: level 1 is S, maxed out by 75mg; and level 2 is N. Guess when level 2 (N) really kicks in? 150mg.
So anything after 150mg is really two systems at once, with the N increasing from there. 300mg is the same amount of S as 150mg, but the N is more.
Would you expect 75mg Effexor to be generally more efficacious than 40mg Celexa? No, because they are both doing the same thing: blocking about 80% of serotonin transporters. But what about after 150mg, when you have S and N?

From An Inconvenient Truth, 2006

This is why Effexor studies only show superior efficacy at doses above 150mg-- because at 150mg, you start adding N on top of your already maxed out S. It's not adding more of the same drug, it is like adding a second drug. It's not more Effexor; it's taking a maxed out SSRI, and adding a NRI. It's like being with Princess Leia, but then adding Princess Ardala. And if you understood that joke, you should put down Yars' Revenge and kill yourself.
Let me be clear: I'm not saying Effexor is or is not better than an SSRI. I am saying that
it would be impossible for it to be better then SSRIs, across a population, at less than 150mg.
if it is going to be better, it would be better after 150mg, and only because you are adding a second system.
If you are a doctor who "went all the way" up to 75mg Effexor for depression (or 300mg Seroquel for psychosis, etc, etc) and then stopped it because "it wasn't helping at all" then you should probably punch yourself in the testicles/uterus, you have missed the point. How one responds at 75mg IS NOT AT ALL PREDICTIVE of what might happen at 150 or more (or, for Seroquel and psychosis, 500mg or more) again, and for the last time, because higher doses aren't more, they are different.(2)

You can see this most clearly if you look at an MRI:

which is self-explanatory.(3)

What you may want to ask is this: why haven't you heard this stuff before? You think I discovered all this, in my basement lab, the one I use to create Jessica Simpson clones? I'm the Ponce de Leon of psychiatry?(4) Why the accepted delusion that a drug is the same, regardless of dose? Perhaps it's because this supposedly only applies to the newer drugs? The old ones-- Thorazine, Elavil, Pamelor, Remeron, Wellbutrin-- all blunt instruments, single receptor system drugs?
Why do we think that an inanimate object has a fixed identity, when even a person doesn't?

Next up: Aren't Two Drugs Better Than One?
--------
1. From the Celexa package insert: (warning: PDF-- clear your schedule)

2. Punching yourself in the testicles/uterus is not likely to help you learn this, it is more for my benefit.
3. It's technically an fMRI, bt the point is the same.
4. Ponce de Leon did not actually discover psychiatry, but he was the first to make it available to the masses.

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===== ====== ===== The Last Psychiatrist: No One Likes A Sure Thing

Parkinson's patients had their dopamine agonists (Sinemet) stopped, and were then told that they would be assigned to one of 4 groups:

You have been randomly assigned, like pulling numbers out of a hat, to Group A. As you read in the consent form, this means that you have a 25% chance, or 1 in 4 chance, of receiving active Sinemet... We took one real Sinemet pill and three placebos and shook them up and withdrew one. This is what we are giving you.

Group B was 50%, C was 75%, and D was 100% chance of getting Sinemet.

In reality, everyone got placebo; all that was different was the patient's expectation of receiving Sinemet.

Those who were told they had a 75% chance of getting Sinemet exhibited a maximal (placebo) response. It was the same amount of clinical improvement, and the same amount of actual dopamine release, as they exhibited back when they were still taking their meds.

This is actual dopamine release (as measured by the decline of a tracer):

and this is clinical improvement:

Interpret this as "less than 50% chance of getting Sinemet meant very little response; more than 50% meant more response."

Perhaps they had a placebo response to the symptoms ("hey, I feel better") which then caused a subsequent release of dopamine, especially in the nucleus accumbens which is the "reward center"? No: dopamine release was entirely dependent on the expectation of the medication.

Think about the words. When you are told it's a 50% chance of it being Sinemet, you are checking with your body to see if it is Sinemet. When you are told it is 75% chance, you are expecting it to be Sinemet.   50% marks a turning point between skepticism and expectation.

Now think of the placebo effect in most other scenarios, e.g. clinical trials: "you're going to get drug or placebo." Imagine, instead, that they told you, "there's a 75% probability of receiving placebo."

II.

So what would happen if you were told that there was a 100% chance of receiving Sinemet, i.e. you were lied to?

Why would 100% certainty result in less dopamine release, and less clinical improvement, than 75%?

Because the placebo response is not simply the body reproducing the effect of the real drug. The placebo response is a reward; and if there is no reward, there is no response.

It doesn't matter what kind of placebo response you want-- pain/endorphin release may not seem dopamine related, but the results would probably be identical. It appears that all placebo responses are substantially mediated by the reward circuits. These are unconscious and immediate. Expecting a response is the same as expecting a cookie, the same pathways are used; and, conceivably, they can be destroyed in the same way.

A more scientific explanation is that the tonic, sustained increases in dopaminergic activity preceding the presentation of a reward are related to the level of uncertainty. 50% probability of reward represents maximal uncertainty, and hence maximum dopaminergic activity. ("Is it going to happen?") It declines like an inverted U from there ("I'm more sure it is/is not going to happen") to zero when you are completely sure.

Another way to say it is: the more that you are unconsciously making a reward prediction (nucleus accumbens), the greater the effect; but certainty bypasses this, leaving no reward contribution to the final clinical effect. In that case, it's all up to the pill.

III.

Feel free to extrapolate.

===== ====== ===== The Last Psychiatrist: No One Noticed

sell in May and go away

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===== ====== ===== The Last Psychiatrist: No Self-Respecting Woman Would Go Out Without Make Up

For some reason, one of the most emailed articles from the NYT was an article about whether women should or should not wear make up. "New York Times? Sounds progressive." Yes.

Seven people were asked their opinion in a column called "Room For Debate," liars, there was no debate, all of them said "I guess so", their main contribution was the hedge: "it's a woman's choice." So while pretending this was some kind of debate with contrasting opinions, all of them had the same opinion, which should automatically signal to you it is the wrong one.

When they say, "it's a woman's choice" what they mean is "it's not a man's choice, it is thoroughly stupid to wear make up just for men, the only acceptable reason is if you do it for yourself, if it makes you feel better about yourself."

Let me offer a contrary position, unpalatable but worth considering: the only appropriate time to wear make up is to look attractive to men.   Or women, depending on which genitals you want to lick, hopefully it's both. "Ugh, women are not objects." Then why are you painting them? I'm not saying you have to look good for men, I'm saying that if wearing makeup not for men makes you feel better about yourself, you don't have a strong self, and no, yelling won't change this. Everyone knows you shouldn't judge a book by its cover, now you're saying the cover of the book influences how the book feels about itself?

I am not doubting that in fact you do feel better about yourself, I am saying that that fact is both pathological and totally on purpose. Since this cognitive trick does help you feel better about yourself, by all means go ahead, but at what point will you stop pressuring other women to go along with it? When will you stop "requiring" it, like when you say, "oh, she's so pretty even without makeup" as if the default was makeup?

The fraud women now believe is that it is wrong to look good for men only, as an end in itself; the progressive delusion is that looking good for men is synonymous with submissiveness, so while you're allowed to look good to men, it should always be secondary to looking good for yourself. This is madness. You are enhancing your outward appearance, which is great, but then you pretend it's for internal reasons?

How would you like to live in a world where men had to wear make up? "Oh, I love make up on a guy, especially eyeliner." Of course you do, you're having a stroke. Ask it this way: how would you like to be in a world where men said," oh, I feel so much better about myself when I'm wearing makeup." You'd run for the nearest totalitarian regime.

The trick to the makeup debate is that it pretends to want to be free of male pressure, yet the pressure to look a certain way is actually much worse from women. So this result is that a "patriarchical", controlling force, unacceptable if coming directly from men, is maintained by giving the whip to other women. No boss man would survive if he said, "ugh, you should put on some makeup, doll yourself up a little bit" but women say this to other women all the time-- especially at work. "You look really tired," says a woman in MAC Greensmoke to another who isn't. Just once I wish the reply would be, "I am, your husband kept me up all night." Not very progressive, but hilarious.

The evolution from "enhances sexual attractiveness" to "doing it for yourself" is definitely a regressive step, and by regressive I here mean "regressing to age two", but it's the next step which reveals the presence of a neurosis: recruiting science as a justification for behavior: "Study finds makeup makes you appear more competent." Can't wait to read about that study in a Jonah Lehrer book. Ugh. So here's the evolution of feminist theory, take notes: "I want to look better" to "I want to feel better about myself" to "I want people to think I am better." Madness.

The further clue that the problem is not gender but... you... is that you find this pseudoscience while you are browsing the internet, i.e. it is your entertainment, your free time; your leisure time is spent justifying a behavior you can't not do. "But I wasn't looking for those articles, I just stumbled on them." Exactly.

The reason the makeup debate is insoluble is that it's not yours to solute. The choice to wear makeup is no choice at all, I know you think you came to it on your own but you live in America, you don't make free choices here, freedom is a brand. Makeup is an $8B/yr industry, that's face makeup alone, no way is it going to allow you to make a choice that doesn't involve a credit card, fine, if you don't like makeup here's a remover for $30, just remember that you're not doing it for men, you're doing it for yourself.

II.

I had used all the porn on the internet, so I turn on the TV, and there's a marionette called Diane Sawyer interviewing 20 female Senators, the most in history, applauding and giggling as if cold fusion had finally been discovered. Of course it's a "good thing" that women are Senators in as much as not allowing them to be Senators is the bad thing, but other than that, what does it mean? That women are finally brave enough to run, or America is brave enough to hire them? It's not like the Capitol Building was turning them away, so why is this important? I knew I was being scammed because I was being told this was a historic accomplishment by the ABC Network. The ABC demo is not ever going to be a Senator, I would bet ten bazillion dollars they couldn't even name one of their Senators and a gazillion bazillion dollars they have no real idea what Senators do, so why is this on prime time ABC?

I think the answer is supposed to be, "it's empowering to women", but you should wonder: when more women enter a field, it means less men did, and if the men stopped going there, where did they go? Why did they leave? I assume they aren't home with the kids, right?

I don't want to be cynical, but boy oh boy is it hard not to observe that at the very moment in our history when we have the most women in the Senate, Congress is perceived to be pathetic, bickering, easily manipulated and powerless, and I'll risk the blowback and say that those are all stereotypes of women. Easy, HuffPo, I know it's not causal, I am saying the reverse: that if some field keeps the trappings of power but loses actual power, women enter it in droves and men abandon it like the Roanoke Colony. Again we must ask the question: if power seeking men aren't running for Senate, where did they go? Meanwhile all the lobbyists and Wall Street bankers are men, isn't that odd? "Women aren't as corrupt or money hungry." Yes, that's been my experience with women as well.

This works in reverse, too, take a field traditionally XX-only, like nursing, and, huh, what do you know-- at the time where nursing is more powerful than it has ever been, there are also more XY in it than ever. But who made it more powerful? It wasn't nurses. And if you're playing that game, ask if the reason "sexy nurses" as a fetish dropped out somewhere around the 90s had nothing to do with females finally getting control over their sexualization but exactly the opposite, men came in and unsexualized the joint. "I'm not gay." Easy, Focker, no one was implying anything.

I know to a woman it must feel good, "yay, I'm a Senator!" and I do not minimize the individual accomplishment of a woman becoming a Senator. But for everyone else, what is the significance? One of the Yay-Women senators suggested that the government would benefit from all the makeup because "women's styles tend to be more collaborative," and at the exact same moment she repeated the conventional wisdom's horrendous banality she simultaneously got married to the head of a lobbying firm. That's progress, I guess.

The problem isn't with women in the Senate, but rather its celebration, which these dummies blindly participate in. Is it putting on a face for the American public, the way the first face I see on Goldman Sachs's website is a black woman? Is it cosmetic? She's probably proud, she should be proud, that she made it to GS, but for the rest of blacks and women, what is the significance? It may be regressive to ask this, but it is illuminating: "hey.... why did they let so many of us in?"

This is part of a larger, systemic problem with the way power has shifted not from Group A to Group B, but from ground up to top down, and top down works in a very specific way: it concedes the trappings of power while it retains the actual power.

III.

In this case, you are seeing a shift of power be repackaged as a gender battle. And it's quite apparent that power is a generation or so ahead of you, so in 1990 a 40 year old who grew up around successful lawyers then says to his 5 year old, "daughter, you should become a lawyer!" and she probably at one point collaborates to decry the lack of female role models, and then by the time she graduates law school she discovers she's a dime a dozen, power has been withdrawn, one step ahead; and at this rate I fully expect 2013's Aspirational 14% to nudge their 5 year old daughters towards investment banking so they can be part of the big Women In Investment Banking conference of 2033. Don't bother, it'll be in Newark.

I can't predict the next field of power, I'm happy to hear your projections, the point for now is that while power moves ahead of you and your family, it leaves behind the appearance of a gender (or racial) struggle; and the immediate result of this is that people consider it a societal achievement that they are merely playing, even if what they are doing is ultimately meaningless. So while women (appropriately) fought for, and got, equal access to college educations-- and now women even outnumber men in colleges-- today we find that college is irrelevant. Huh. NB: what women did not fight for, and this is to my point, is the specific power of being taken seriously without a college education. "But how will the world know we're equal?"

The focus here, again, is why did/do women fight so much for what became irrelevant? Why does this happen all the time? More specifically, did they pursue it because they thought it had power, or did they pursue it because it had the trappings of power?   I'm not being a jerk, it is a deadly serious question. If some dentist fires his hygenist because she's too pretty the United States Of America goes to Defcon 1, but if Goldman Sachs doesn't hire enough women some idiot at The Atlantic writes a fluff piece. "They apparently have a sexist culture there." You know they rule the world, right?

I know, I know, women get paid less then men. Sigh. There are a million reasons for this, but the most important is the simplest: some people want to get more money from the job, and some other people want the job to offer them more money, and they are not the same people. Typically the former is men and the latter is women, but the point isn't gender but the mindset: the latter group wants the job to want to pay them more, they don't want to have to have any input in deciding their own reimbursement. I have this conversation with women a lot, every time it goes exactly like this:

Her: They only offered me $X.
Me: Why didn't you ask for more?
Her: I don't know... I was just happy to get the job.

And I throw up my hands, nothing I say will convince this senator to try harder for herself. I have this same conversation with men as well, less frequently but not never, though the conversation is slightly different:

Him: They only offered me $X.
Me: Why didn't you ask for more?
Him: I don't know... I was just happy to get the job.
Me: What are you, a girl?

Works every time.

IV.

Everything you need to know about how the system sees you is expressed in its purest way in ads. So, completely off topic, here's an ad, relax, this has nothing to do with guns:

I had never seen this ad, because the ad was not for me. The ad targets men who need a gun to feel like a real man, the gun validates their masculinity-- or so the ordinary, pseudo-feminist deconstruction would go.    Except that's not what the ad says. It says, quite clearly, that the highest validator of masculinity isn't the gun, it is the card.

You've been trained to look at these things in terms of gender, forget it, the pathology of the generation is narcissism, the ad knows about, and works only on, a society eyeballs deep in narcissism, that requires its identity broadcast by branded objects but validated by other people. Because what this ad says, explicitly, is that owning the gun doesn't make you a man; when you own the gun, some other omnipotent entity will declare you a man.

I'm not saying that gun owners need to show their guns off, I'm saying this ad assumes that. There was a time where merely possessing the fetishized object was enough to self-identify ("I'm awesome, I'm having sex with a blonde"; "just having my 9mm inside my jacket makes me feel bad ass"), but this is no longer sufficient, it is no longer powerful enough to penetrate your thick skull, you have to be able to show it to someone else, to watch their eyes light up in recognition for you to know you have convinced them of who you are.

Is it cosmetic? Note the logic has evolved from "you'll feel better about yourself" to "other people will see you as more competent."

Forget about the gun/masculinity interaction, it is a red herring; the problem is the cycle of wanting outsiders to tell you who you are, which is why empty celebrity works just as well as accomplished celebrity, which is why you can't tell if Kanye West is downgrading to Kim Kardashian or she is downgrading to him.

But right on cue, the most deluded of women, not just a feminist but a self-proclaimed "feminist evangelist," showed up and completely missed the point, so she changed what was a clear example of the generational pathology of narcissism, and repackaged it as a gender issue:

"We?" As in, "we at Feministing?"

If you follow that the consumer unconsciously understands that his masculinity is approved from the outside, by other people, then Valenti is the very person that the ad is arguing against: "these bitches think you're not a man. We at Busmaster tell you differently. Who are you going to believe?" Hell, I'lI believe a Sleestak before I listen to Jessica Valenti, really, those are my only two choices? The ad had no effect on me; her tweet makes me want to join a militia.

Note she doesn't really want to discuss it, she assumes it's self-explanatory, as if the very fact that masculinity and guns are related is itself bad, as if the solution was to uncouple the two. But what would happen next? The problem, as above, isn't the gun but the need for external validation, which means if you take the gun away something else must replace it, and it won't be what works for her, e.g. exposed brick and that great show Girls. "It's great!" It's horrendous.

V.

To understand exactly why "feminism" or whatever Valenti thinks she has re-invented has not only stalled, but is damaging to all humanity, all you need to do is go to the source. Totally at random, I went to Huffington Post Women. Let's see what the feminists are up to, here are the top five articles:

1. The Reason The Academy Passed On Kathryn Bigelow (answer: sexism.)

2. Confessions Of A Mistress (protip: "Here's the wisdom I can offer to mistresses out there: do not get too attached.")

3. Why You Should Be Nervous-- And Yet Not-- About Sunday Night (since the Golden Globes conflict with Girls, just DVR Girls, and anyway Lena Dunham will be at the Globes.)

4. 'Girls' Star Talks Nudity And Season 2 (I refused to even click it)

5. Meet The Woman Who's Only Eating From Starbucks

Look, it's easy to make fun of these articles, my point isn't that sometimes women read nonsense. The point here is that they are branded as for women, this is what the Huffington Post Women thinks of women, they suspect, apparently rightly, that women will respond better to these articles if they are told they are "For Women."

Here's a quote from #5, the woman who is eating Starbucks for a year:

So how can eating only one company's products impact me, anybody? Well Mr. McDonald's already proved that question years ago with his documentary and Mr. Subway did his take on the loosing weight portion of the food challenges too. But when I watched those guys doing their thing I asked myself "where are the WOMEN challenging themselves in the world?" "Where are the effects being shown on a woman's culture? A woman's family & children? A woman's diet, weight, fashion, checkbook, community and world through challenges?" "Where is HER VOICE on how an international company is directly or indirectly impacting everything from her waistline to her bottom line and every other woman's, man's, child's, societies and planets world with their presence?"

What's crazy about this crazy person is that she's crazy, if she did this in the name of her own psychopathology we could happily ignore her, but she's doing this for women, she's saying it's for women, when what you want to say is, "you know this makes people hate women, right?" Mr. McDonalds didn't do it for men, or even as a man, he just did it, why do you have to drag the rest of the women into your delusions?

But this is the kind of solidarity popularized by Lori Gottlieb and the rest-- and I am asking, at what expense? Sites like Jezebel and Feministing are much, much worse than pornography, every article they write sets women back a week, do the math, they do such a disservice to women because they take their narcissism and repackage it as gender issues, and you're locked into it. What if I don't think gun control is a gender issue? What if watching Girls makes me want to make a snuff film? To use your impossible language, "where is my safe space to challenge your privilege?"

My point isn't that women don't have legitimate gripes with the system, or that there isn't sexism still around, my point is that most of what you think is "feminism" is really a work, a gimmick, a marketing scheme. It is straight up consumerism, repackaged as a gender issue. Case in point: season 1 and 2 of Girls.

And most importantly of all: if this is what women's solidarity is made of, how much support can they really expect from each other? Is this solidarity power, or the trappings of power? "Did you see Girls last night?" No, I'm sorry, I was being raped. "Oh, too bad. It was a good one."

VI.

In Django Unchained, evil slaveowner Leonardo DiCaprio asks a question. Sorry, back up: why does everyone call him an evil slaveowner? As far as I can tell, he was a pretty average slaveowner, I'd even say he was "kind", in the sense that all his slaves "like" him, and he rarely "tortures" anyone and by the use of quotes you can see I'm hedging, my point here is how quickly people have to broadcast their indignancy. "He's evil." So what you're saying is you're against slavery? Thanks for clarifying.

This explains the near-universal anxiety over the movie's frequent use of the word nigger, and someone asked Tarantino if he thought he had used it too much in the movie, and his response was perfect: "too much, in comparison to how much it was used back then?" Nigger, and the violence, was all anyone was upset about. Terry Gross, NPR's mental Fleshlight, asked Tarantino her typically insightful and nuanced questions: "do you enjoy violent movies less after what happened at Sandy Hook?" Sigh. So there's the Terry Gross checklist for reviewing Django: gun=bad and saying nigger=bad. Check and check. You know what no one thought badworthy? When the white guy asked to have a certain slave sent to his room to try out her ample vagina, and the prim white lady of the house happily escorted her up. "Go on, do what you're told, girl."

I'd venture that Terry Gross and and the gang at HuffPoWo would rather be whipped than be-- that's rape, right?-- but that scene didn't light up their amygdalas, only hearing "nigger" did. I find that highly suspicious, or astoundingly obtuse, or both.

Anyway, perfectly ordinary slaveowner DiCaprio asks a rhetorical question, a fundamental question, that has occurred to every 7th grade white boy and about 10% of 7th grade white girls, and the profound question he asked was: "Why don't they just rise up?"

Kneel down, Quentin Tarantino is a genius. That question should properly come from the mouth of the German dentist: this isn't his country, he doesn't really have an instinctive feel for the system, so it's completely legitimate for a guy who doesn't know the score to ask this question, which is why 7th grade boys ask it; they themselves haven't yet felt the crushing weight of the system, so immediately you should ask, how early have girls been crushed that they don't think to ask this? But Tarantino puts this question in the mouth of the power, it is spoken by the very lips of that system; because of course the reason they don't rise up is that he-- that system-- taught them not to. When the system tells you what to do, you have no choice but to obey.

If "the system tells you what to do" doesn't seem very compelling, remember that the movie you are watching is Django UNCHAINED.   Why did Django rise up? He went from whipped slave to stylish gunman in 15 minutes. How come Django was so quickly freed not just from physical slavery, but from the 40 years of repeated psychological oppression that still keeps every other slave in self-check? Did he swallow the Red Pill? How did he suddenly acquire the emotional courage to kill white people?

"The dentist freed him." So? Lots of free blacks in the South, no uprisings. "He's 'one in ten thousand'?" Everybody is 1 in 10000, check a chart. "He got a gun?" Doesn't help, even today there are gun owners all over America who feel that they aren't free. No. You should read this next sentence, get yourself a drink, and consider your own slavery: the system told Django that he was allowed to.   He was given a document that said he was a bounty hunter, and as an agent of the system, he was allowed to kill white people. That his new job happened to coincide with the trappings of power is 100% an accident, the system decided what he was worth and what he could do with his life. His powers were on loan, he wasn't even a vassal, he was a tool.

This is not to minimize the individual accomplishment of a Django becoming a free man. But for the other slaves, what is the significance?

Of course Tarantino knew that the evil slaveowner's question has a hidden, repressed dark side: DiCaprio is a third generation slave owner, he doesn't own slaves because he hates blacks, he owns them because that's the system; so powerful is that system that he spends his free time not on coke or hookers but on researching scientific justifications for the slavery-- trying to rationalize what he is doing. That is not the behavior of a man at peace with himself, regardless of how much he thinks he likes white cake, it is the behavior of a man in conflict, who suspects he is not free; who realizes, somehow, that the fact that his job happens to coincide with the trappings of power is 100% an accident... do you see?   "Why don't they just rise up?" is revealed to be a symptom of the question that has been repressed: "why do the whites own slaves? Why don't they just... stop?" And it never occurs to 7th graders to ask this question because they are too young, yet every adult thinks if he lived back then, he would have been the exception. 1 in 10000, I guess. And here we see how repression always leaves behind a signal of what's been repressed-- how else do you explain the modern need to add the qualifier "evil" to "slaveowner" if not for the deeply buried suspicion that, in fact, you would have been a slaveowner back then? "But at least I wouldn't be evil." Keep telling yourself that. And if some guy in a Tardis showed up and asked, what's up with you and all the slaves, seems like a lot? You'd say what everybody says, "look wildman, don't ask me, that's just the system. Can't change it. Want to rape a black chick?"

IV.

Speaking of no one being upset about rape, here's a story, starts out bad and gets even worse in ways you won't expect: a 16 year old girl is passed out drunk at a party, she is then allegedly raped by a/two high school football players, and carried unconscious to other parties and displayed and/or raped, and apparently because the town has a "football culture" no arrests are made, it's hushed up, the boys are protected, and I think to myself, oh, that's weird, is that town still in 1986? True story: in 1986, at a mixer at the Delta Gamma sorority house, Lacoste Football Guy gets hard for 16 year old sister of Benetton Girl, and in order to get her jeans off he hits her in the head with a lamp, so in order to keep her jeans on she kicks him in the mouth, and through the blood and fury he's screaming he'll sue her, do you know who my father is? NB: he went on to become a lawyer and no I am not making that up.

"Ugh, even now, 25 years later, it's still a hypermasculine rape culture." Ha! No. Hypermasculine? Where are you, the Dominican? No, what's amazing/obvious is how after 25 years of Diane Sawyer and makeup debates, not one other girl at this party came to the victim's aid; not one girl saw what was happening at the party and simultaneously called 911 and Facetimed the crime; not one girl called all the women she knew and brought the wrath of Athena down on that town. Nope. Nothing. A lot of laughing and giggling though, turns out rape is funny, someone owes Daniel Tosh a huge apology. "Women's styles tend to be more collaborative." I can tell, they collaborated to keep their mouth shut. In 1986 the sorority girls also collaborated to blame the victim for for being so rough with Lacoste Guy: "How could you do that to him? His face is like, totally corroded." Hey, come on, look how he was dressed, he was asking for it.

"We need more women in power." Wrong preposition, dummy, but anyway you have them. You have judges and prosecutors and twenty female senators, what has it gotten you? Your own ground floor women don't protect each other, you know who had to come to this teen's aid? Anonymous. Men.

Of course I don't know if the boys really did these things or not, ok? But if the reason the boys were protected was the "football culture," that means people in the town were taught to protect them. And if the girls did nothing, it means they were taught to do nothing, and the people most responsible for that lesson was other women.

"No, the town was corrupt, they swept these kinds of things under the rug for years." If you've known for years the town isn't going to help women, if you've known for years it's a "hypermasculine rape culture," wouldn't that make women want to stick together more?

It's not like these teen girls were denied an education or had to endure sexual harrassment at work or had to go to Sweden to get abortions, if there was ever a generation that should feel most empowered it would be them, yet they-- not just one of them; all of them-- "knew", somehow, that they could/should do nothing. Which means that they were taught that from somewhere, and the only place that it could have come was older women. "The other lesson is: makeup is a choice." Today I learned nothing.

There's your female empowerment, there's you feminist progress, catastrophically subverted from the top down, like it's in an abusive relationship, satisfied with the house and the car and the 4/7 good days and simply doesn't want to rock the boat so it expends frantic energy on what is ultimately nonsense.   Every stupid parent teaches their girls not to get raped, duh, but have any mothers spent any time indoctrinating their daughters what to do if another woman is being raped? Have they made it a reflex to defend, to attack? "Isn't that obvious?" Ask the town. "We need to support each other!" sure, as long as it's from the safety of a computer monitor or a 5K, yay women. Have you explicitly told your daughters that if a woman is passed out drunk and you see a Notre Dame Hat climbing over her couch, it is your responsibility to grab an aerosol can and a lighter and threaten Armageddon, or at the very least yell stop?    "Well, that's kind of dangerous." Yeah, that's kind of the point, but I grant you that it's safer to giggle and let boys be boys. Do you want power, or the trappings of power? Somebody's going to have it, you can't make it vanish. I wasn't at this particular rape, the town's defense amazingly appears to be she was a slut and she was asking for it, and my point is: so what? Why didn't the other women stop it anyway? Why didn't they just rise up?

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===== ====== ===== The Last Psychiatrist: Not A Good Month For Blonde Reporters

and not a good generation for everyone else

Honest up, wildpeople, when you heard a TV reporter named Lara Logan got sexually assaulted by a gang of hooligans, how much did you want to see what she looked like? Lara sounds hot. And how certain were you that to find out, all you'd have to do was click the link?

Is rape a crime of sex or a crime of violence? Better to ask: how good is your psychic filter that you can find sexiness in pretty much anything? You didn't picture her bloodied and crying, you imagined her reluctant. How easy was it for your mind to turn "gang rape" into gang bang"? You don't have to answer; I live in the same country you do.

The story seems to be that she was raped by a bunch of hooligans, but that story is long gone in favor of the louder one, the one that's everywhere: did her looks have anything to do with it?

Years of cognitive retraining have finally taught us not to ask that question, though only because we're now in general agreement that looks have everything to do with it. Oh, I know, not all rapes-- just the ones you're going to hear about in the media.

Media producers, my pet name for the Chthulu, have pretended to be appalled by the public's wonder if Logan's blonde hotness had anything to do with her rape, but it's hardly the public's fault-- they made her hotness the story.   I knew she'd be Victoria Secret hot the moment I heard the story, partly because I assume they only hire hot reporters but also because I know they wouldn't bother screaming the story at me if she wasn't. Do they ordinarily reveal the faces of rape victims in other cases? Well, here's one so you don't have to google it.

But they're not telling you she's blonde to suggest that's why she was raped, they're telling it to you to read the story. And when they tell you that you are a misogynist jerk for thinking that her swimsuit model body had anything to do with her attack, I hope you can see that they are telling you that so that they have an excuse to mention that she had a swimsuit model's body. Like Arthur challenges Saito, "don't think about elephants. What are you thinking about?" Son of a gun, inception works.

Are there any among you who read the story but didn't wonder if she was good looking? Ladies, no one's looking, you can be honest.

So don't let the media tell you her looks aren't an issue, I have no idea whether they weren't an issue in the rape but they are most certainly an issue in the story, which is all they care about, and which becomes your entire data set of the world.

II.

You know what I don't know about Lara Logan? Who raped her. Pro-Mubarak or anti-? Too bad, that's what I want to know, so I know whether to write the country off for the next decade or the next five decades.

Oh, refreshingly, the media has refrained from the reflex racial apologistics that follow American crimes, "not all Egyptians are rapists" and "this isn't indicative of all Egyptians," but the media has to hold off because we don't know who did it, the media isn't sure which way they want to go. Once we know for sure, you won't have to fire one synapse to figure out if this is indicative of all Egyptians or not, they'll Matrix it out for you in news reports, TV shows, and commercials. Stay tuned, the next generation of foreign policy axioms brought to you by the producers at CBS.

III.

It isn't a good month for blonde reporters on location. Some other swimsuit model tried to get the words out right, tripped over the first, and then like dominos all the words went down, down, down, and there's only one valid interpretation: her brain misfired.

The story is that she maybe had a stroke; but the story of the story is that the media want to get out from the shadows and become the story, and any chance they can get it-- and at anyone's expense-- they will take it.    No one wants their reporters to have strokes or get gang raped, but no one should let a good crisis go to waste, either, it's an opportunity to do important things that you would otherwise avoid, thank you very much Mayor Emanuel. Maybe we had a good reason to avoid certain things? I will point out that the entire pubic discourse on these reporters does not ever mention the content of the original story-- what was Logan about to report? What words was Branson trying to get out? Oh, that's not important. Then why did we have her out there in the first place?

oh, now I see

It's hard to summarize the extent of the damage that the news media inflict on each individual's psyche because it all seems so appropriate: shouldn't we want more information, not less? That way we can pick and choose what's important to us? It makes some sense, yet it still takes me weeks to pick a computer that is identical to all my other choices though none of which are really appropriate to my needs. Information bias is a steel death trap, once you're in you do not want to come out. But there are only 24 hours in a day, and with sleep and porn and driving and drinking, what you know about the world comes in brief soundbites, and the minutes you spend knowing about Branson and Logan are minutes you don't know something else, and worse, you think you can extrapolate from these pop culture images to a sophisticated understanding of finance and politics. You can't, there's no time left for thinking. I know you think you're above pop culture and stick to news, but all of this is pop culture and you're eyeballs deep in it and there is no where else to turn. I guess I'm guilty too, having just spent hours writing about this, but I justify it by saying someone has to make this explicit, someone has to let you know that these maneuvers and seductions aren't incidental but wholly the purpose, sure they know it's dumbing and wrong but that's the game, everyone's gots to get paid, you may not be interested in pop culture but pop culture is interested in you.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Not Competent To Make Medical Decisions?

As a forensic psychiatrist, I am often called to evaluate someone for their "competency"-- to make medical decisions, to make financial decisions, to stand trial, and (theoretically) even to be executed.

In these various consults, the basic question is this: are they so impaired, that they don't understand the relevant issues and can't make rational decisions?

Many psychiatrists find this complicated and time consuming work, because they focus on the nuances of the patient's symptomatology and illness. They try to get extensive past histories, corroborating information, etc, etc. All this is important, but they miss the forest for the trees.

Now this is, of course, only my opinion. But it's important that you hear this opinion, because I am, apparently, the only person who has it, so you won't hear it anywhere else.

The truth to competency evaluations is this: the patient is the least important factor.

First, everyone is assumed to be competent, not incompetent. There's no such thing as
"evaluate for capacity to refuse treatment"-- there is only "evaluate for the lack of capacity to refuse." The default condition is competent. It is up to the clinician to show sufficient evidence to take away his right to make decisions; not up to clinician to determine if he can make decisions. And in order to take away their rights, you have to have an exceptional reason. Not a valid reason, an exceptional one. Not "benefits outweigh risks" but "treatment is so urgently necessary that it justifies this gigantic suspension of his civil rights."

For example, if a patient is preposterously psychotic: eating feces, seeing aliens, channeling the Devil, and he has a temperature of 100 and you want to give him a Tylenol and he says no, can he refuse? Can you force him to take it? Absolutely he can refuse, no way can you force it. Even if he doesn't know what Tylenol is; even if he thinks it's a mind control pill from the CIA. Because the relevant factor is the Tylenol-- it is not necessary-- not his psychosis, not matter how severe.
You can actually determine compentency without seeing the patient. No lie. Observe:
Surgeon asks if a patient is competent to refuse a necessary surgery. Ok, when's the surgery? "Next Thursday." Consult over: competent. If it can wait until next Thursday, it isn't urgently necessary, and it doesn't matter what his reasons for refusing are: you can't force someone to do something unnecessary right now. On top of this, capacity evaluations are time sensitive; it's competency now, at this moment-- you can't judge whether they will or will not be incapacitated in the future. Again, note that in this example, I didn't describe the patient's mental state; it isn't relevant. What's relevant is the simple question: is there any overwhelming justification for me to force someone into this?

Doctors have a very difficult time with this concept, so I'll give you an analogy: innocent until proven guilty.

So residents want very badly to tell me about the history, the symptoms, that the patient is depressed or delirious-- in more than half of their case presentations, they never even mention the required treatment ("it's a competency eval to refuse treatment")-- and their frustration with me is palpable ("wait, just let me tell you about his---") because I keep interrupting them to ask about the necessity of the treatment.
I'll repeat: the treatment is the important thing, not the patient. Competency/capacity evaluations are situation specific. There is no such thing as "incompetent to refuse treatment"-- there is only the specific case at hand: incompetent to refuse this one specific treatment in this one specific case at this one specific time." Only judges are allowed to decide general imcompetence. You're not a judge, are you? Then shut up.
And thus we come to the point: as clinicians trained in medicine's implicit system of parens patriae, they think they should be allowed to overrule the patient to do what's best for them.

And you say: well what's wrong with that?
First, what the doctor thinks is best is irrelevant. We are talking about "substituted judgment" which means "what the patient would have wanted if he were competent." This is not the "best interests" standard, in which doctors decide what's in the "patient's best interest." The two might be different.   So again, the standard is not what the doctor thinks is right, but what the patient wants. Period. You don't like it? Go back to Russia.
Second, is the "slippery slope" argument. If you're allowed to usurp a patient's rights to give them non-emergent treatment, where does it stop? Can you force psychotics to stop drinking or smoking? etc, etc.
Third is the reverse problem: if you are allowed to usurp their rights for non-emergent treatments, are you therefore obligated to do so? Is it your job to chase them around and make sure they take their digoxin? And if they don't-- then what? Involuntary commitment?   Slip it in their drink? Really? If my wife dies of digoxin toxicity because the doctor gave it in her drink, but her other doctor was slipping her Lasix, who do I stab?
Fourth: what if the doctor is wrong? Maybe the patient knows what's best for himself, given the context of his life? I mean, it could happen, right?

And the fifth problem is political: if a clinician can determine what's best for patients-- even if its not emergent-- why can't the government? Because they're not clinicians? How about government doctors? ("The U.S. Corps of Psychiatrists have decided all Democrats need Zyprexa." Like that?) It amazes me how obvious it is to many doctors that they should be allowed to do "what's necessary"-- forced antipsychotics, involuntary commitments, etc-- and these same doctors are apoplectic over Guantanamo.   Under what possible logic can we allow that a psychiatrist should be allowed to detain a patient against his will, for the safety of others, and not allow the government to do the same? Oh, you think you are in a better position than the government to decide who is dangerous and who is not? Then look around you, ye mighty, and despair.

Let me explain to you the bind that you psychiatrists have put yourselves in. If a guy says he's going to kill his girlfriend, then you're obligated to protect and/or warn: you hospitalize him, or call her, or both. But if you decide he is not in any way under the influence of psychiatric illness, and you decide you should simply call the cops to let them handle it, you'll find they have absolutely no obligation to do anything because no crime has yet been committed. Despite the fact that the side of the police car says "To Protect And Serve" they have no legal obligation to do either-- but, here's the kicker--you still do! If he kills his girlfriend, you get sued, not the cops. Think about this.

For the record, I'm not saying the government should have this power, I'm not saying Guantanamo is a good thing; I'm saying doctors shouldn't have the power either.

Before you argue with me, understand that I am not trying to be dogmatic, I understand the nuances of everyday practice. But this is a power you do not want, you should use it with reluctance and care, because every time you use it it hurts you, it chips away at the wall that stands between you and society, the wall that allows you to say, "look, I'm just a doctor, I just treat illness, I can't be responsible for people's behaviors."

----

P.S. It goes without saying, but I'm saying it-- if you do find someone lacks capacity to make a serious, urgent decision, for the love of God and all that is holy, don't then take it upon yourself to make the decisions for him. Move to a surrogate decision maker-- spouse, kids, parents, relatives, etc; anyone but you!

P.P.S. Also remember that every time you determine a surrogate decision maker is needed, you are also responsible to evaluate that surrogate. It has happened more than once that I suggest the husband as a surrogate decision maker only to find that he's even more whacked out than she is. Don't laugh; you should cry.
P.P.P.S. In Massachusetts, patients who are adjudicated incompetent automatically get the court-- not doctors or family members-- as the surrogate decision maker. Happy now?
P.P.P.P.S. Controversy is heavy, but here are the things that, to my reading of the law, are not allowed to be done without court order: psychosurgery, forced sterilization, admission to psych hospital (but not medical), ECT, and antipsychotics. There is sufficient case law to allow forced antipsychotics in cases of dangerousness or emergency ( Washington; Rogers;), but I'm not willing to concede much more than that.
P.P.P.P-- oh, come on: The Supreme Court has also opined about when it is ok to involuntarily medicate prisoners with antipsychotics: 1) Is it an important government interest? 2) Would antipsychotics further this interest? 3) Are the medications necessary to further this interest? (i.e. is there no other way?) 4) is the antipsychotic medically appropriate? You will notice that without 1), you can't do it. "Important government interests" are things that touch the Constitution, like right to a speedy trial. This is a slightly different situation, but I thought you should know.

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===== ====== ===== The Last Psychiatrist: Not Yet Ready For Porn

Surprising results from the study, "Magnetic resonance imaging of male and female genitals during coitus" in BMJ:
We did not foresee that the men would have more problems with sexual performance (maintaining their erection) than the womenin the scanner.
There is so much wrong with that sentence.

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===== ====== ===== The Last Psychiatrist: Number Needed To Treat

How a relatively unused metric can help you score chicks at the Limelight.
That's right, I said score chicks. You got a problem with that?

Current Psychiatry has an article about Number Needed To Treat which is so staggeringly abstruse that it is nearly unreadable, observe:
A non-statistically significant NNT would have a CI that includes a negative number and a positive number: When comparing intervention A with intervention B, A might be better than B or B might be better than A. One bound of the CI may be a NNT of 10 and the other may be –10. It would be tempting to describe the CI as –10 to 10, but this would be misleading.
and later:
The truth-operation is the way in which a truth-function arises from elementary propositions. According to the nature of truth-operations, in the same way as out of elementary propositions arise their truth-functions, from truth-functions arises a new one. Every truth-operation creates from truth-functions of elementary propositions, another truth-function of elementary propositions i.e. a proposition. The result of every truth-operation on the results of truth-operations on elementary propositions is also the result of one truth-operation on elementary propositions.Every proposition is the result of truth-operations on elementary propositions. Here it becomes clear that there are no such things as logical objects...

which is strange, because NNT was invented specifically to be easy to understand and apply.   Oh well.

Number Needed To Treat is the number of people who would need to receive the treatment before you could appreciate a difference between the treatment and something else.

Remember that one time after the riots when you looted the Rite Aid and grabbed a bunch of pills that you thought were Lexapros, but could be penicillin--how many depressed people would you have to give the pills to before you could be confident that they were Lexapros, and not penicillin? For example, if you give it to two people, and both get better, you can't be certain it wasn't all placebo effect, right? Conversely, if neither person gets better, it doesn't prove they were both penicillins, right? You'd have to try it on more people. How many? Whatever the answer is, that's the Number Needed To Treat.

So NNT is related to the difference between a) how well the treatment works; b) how well the comparator works.

Here's how to calculate NNT: "what is the difference in the rates of success between two maneuvers? Divide into 100."

The year is 1984 and a guy who looks disturbingly like any of the guys from Jefferson Airplane (formerly Flock of Seagulls) goes to the Limelight in NYC to mack some stellas (he still calls them that, but that's because one of them hit him in the back of the head with her husband's fist) and always manages to get one to go home with him: "persistence beats resistance," the bouncer told him, and this proved to be good advice, along with the thing about Halcion, and rolling your suit jacket sleeves up, all of which... wow... really, thanks... outstanding. And the leather tie thing.

(1)

Inside, he gets shot down 8 out of 10 times. ("Whaddya want? They're all dykes. 'WHERE'S THE BEEF?' Ha! I kill me!") Over the course of the year, before he heads to the Hamptons for the summer to frighten women into lesbianism there, his Visicalc spreadsheet shows that the 20% success rate is pretty consistent. 1 in 5 times he's at a girl's breast like a .14 BAL slammed into an airbag. Here, a found a picture of him and his friend doing just that on my internet cache, along with other pics that I told my mom I have no idea how they got there:

A threesome with the guys from A-ha.

So 20% success rate-- -- "1 in FIVE, ace!" That's how smooth he is. He's even more smooth than that guy in the Shakira "Hips Don't Lie" video, no, not the guy from the Fugees, I mean this guy:

Trevor knew if he could just win the dance off, Molly would go steady with him.   But first was the little matter of his invisibility.

But let's say he spent his time simply sitting at the bar and keeping his crap hole firmly shut, never going up to women at all-- they came to him-- maybe they saw his internet profile-- and he still scores 1 in 10 times. So while he can brag to his friends that his rap is so tight (2) that it doubles his success rate (from 10% to 20%), in fact it only raises it 10 percentage points. His number needed to treat is therefore 10 "divided into 100": 100/10=10. He has to actively approach ten extra women to be able to attribute one success to his rap.

So let's review:

his nightly success rate: 100%.
his rap's success rate: 20%
his "shutting up and just sitting there" success rate: 10%.
Here's how these stats would appear in his daily life:
Personal ad in the Village Voice: "100% better! I so rule!"
City Order of Protection: "...risk to the women of New York was increased ten percentage points..."
Case report in Journal of Infectious Diseases: "Number Needed To Harm: 10"

LET'S SAY I WANT TO GET ALL SCIENCEY. CAN YOU USE REAL PSYCHIATRIC EXAMPLES THAT DON'T INVOLVE PEOPLE I WILL EVENTUALLY SEE ON BILL KURTIS'S AMERICAN JUSTICE?
American Justice was canceled, it's now called Where Are They Now? That notwithstanding, here's your psychiatry, from a study done by a bunch of scienticians. What's the Number To Treat for Depakote for prevention of mood episodes in one year?

That's 17, seventeen. STOP PRESCRIBING DEPAKOTE. (3)

In practice, the more studies you can pool together, the more accurate/useful will be your calculated NNT, though simultaneously how you pool data can affect the NNT. Consider two trials, one with 10000 people and an NNT of 60-- but that sucked in design and execution; and another with 50 people and an NNT of 2, but much better design, etc. Simply adding the raw numbers of people together will skew the data in favor of the large but error-ridden NNT.
SO WHAT'S ALL THE FUSS OVER NNT? WHY DO DRUG COMPANIES REFUSE TO PUBLISH THEM?
The NNT helps you decide if the treatment is worth it.
ISN'T THAT WHAT THE FDA IS FOR?
No, the FDA-- wait-- are you serious?
IF YOU KNOW A DRUG IS HELPFUL, ISN'T IT ALWAYS WORTH IT? IF THE DRUG HELPS EVEN A LITTLE, AND HAS FEW SIDE EFFECTS, WHY NOT GIVE IT TO EVERYONE WHO COULD BENEFIT?
Because this isn't France, commtard. Who's going to pay for all these pills?
Pretend a drug exists that can reduce the risk of heart attacks in people with high cholesterol by 50%, and let's call it Lipitor. Pretend it costs $5/day, so $1825/yr. Is reducing the risk of heart attack by 50% worth $1825/yr? I say yes, so long as we're talking about me.
But let's pretend the actual reduction is from a baseline rate of 8% to Lipitor's 4%. So the NNT for Lipitor compared to placebo is 100/4=25. 25 people have to get Lipitor to prevent one heart attack. 25 people is $45,625/yr. Is $45,625 worth it to prevent one heart attack, or, at that price, should we maybe just stop eating donuts?

You can see how an insurance company might not want to cover certain medications. What's amazing to me is how skeptical everyone is about Pharma, how they distrust anything they say, and whine that the drugs are too expensive, but they've all bought Pharma's biggest scam: that these drugs are necessary.

The only way to solve this problem is to force doctors to consider the cost of the medications.
Give the doctor a budget, say, $20/day per patient, and let him choose whatever drugs he wants, generics, brand, doses, etc. "I can give you Viagra if you stop eating donuts and get off Lipitor. In fact, you might be able to use the Viagra if you stop eating donuts."

Doctors hate this, partly because they see individuals and want to maximize gains in that single individual, but mostly because they're lazy. It is much easier to give a drug that works (e.g. Lipitor) than to affect behaviors (e.g. donuts.) But it's only easier because they don't have to think about the cost. Doctors are completely sheltered from the cost analysis, all they see is "50% reduction in heart attacks? I'd be crazy not to!"
The only time a doctor cites prescription drug costs is as a stepping stool to mount his high horse.
Make them pay, things will be different. Then you'll see doctors communicating with one another, psychiatrists with cardiologists, etc, trying to decide what meds to use on a guy. Currently, doctors don't even know what other doctors prescribed in a patient. They don't decide anything-- they hit up the flowchart.
I stand by this assertion: I can reduce overall pharmacy costs by 20%, yet still maintain outcomes. In other words, I can save $20 billion a year. There, I just helped pay for Iraq. I know, you're going to say Iraq isn't worth the money, etc, etc. Bite me. It's not even lunchtime, and I just paid for Iraq. What have you done today? Face!
Here's some NNTs to keep you warm at night:
Ritonavir vs. placebo in AIDS-- death in a year: 14
Aspirin vs. placebo in treated hypertensives-- MI in a 4 years: 208
Flu shot vs. placebo-- flu symptoms in a season: 12
Prozac + folate vs. Prozac alone- depression response in 10 weeks: 5! (Wow?!)

----

(1) Before you nutbags flame me, I know that's not Flock of Seagulls, and I'm not necessarily trying to say they look alike, nor am I trying to imply that one guy, the Flock of Seagulls guy, and the guy from Hall and Oates are in fact the same person, ok? Sometimes people look like other people. (4)

(2) He wouldn't have actually said that in 1984. What he would have said was "Say hello to my little friend!" even though it has nothing to do with the topic at hand, because that's what everyone was saying in 1984. Do you know why? Syphilis, that's why.

(3) Someone is going to email me and say that NNTs based on survival data should be calculated using hazard ratios, and not on the difference in rates. You know what I have to say to that? Go to hell, that's what. I could also respond that both methodologies provide estimates of the NNT, and the difference between the two results is small and inconsequential, and anyway still within the 95% confidence interval, but I'm sticking with go to hell.

(4) Which totally reminds me of a hilarious bit by Patton Oswalt (from memory, so...):
...people are getting plastic surgery to look like famous movie stars, Brad Pitt, George Clooney-- good looking men, for sure, but let's have a little perspective. If they had plastic surgery in the 70s there's be guys walking around looking like Hall and Oates. "Yeah, all right, life is good... I look like Daryl Hall from Hall and Oates... I'm on a pussy train that's never going to derail, never!

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===== ====== ===== The Last Psychiatrist: NY v Junco: Sex, Civil, Hygiene, and Mental, All In One Post

when you lay down with dogs, you come up with fleas

Forensic psychiatrist James Knoll writes The Political Diagnosis: Psychiatry in the service of the law. You should read it (short) now, I'll wait.

If you have the great misfortune to live in NY, as I once did, for three years in a miserable art deco apartment building near 180 and Broadway, sandwiched between Hellfire and Damnation, fighting thugs to get into an apartment you had to fight roaches to get out of-- but I digress.

In any event, the state of New York is pleased to offer civil commitment of sex offenders. How do you determine who is "a sex offender requiring civil management?"

According to the Mental Hygiene Law (yes, it's called that)

" '[s]exual offender requiring civil management' means a detained sex offender who suffers from a mental abnormality. A sex offender requiring civil management can, as determined by procedures set forth in this article, be either (1) a dangerous sex offender requiring confinement or (2) a sex offender requiring strict and intensive supervision."

The second sentence is indecipherable. I think it says, "a person requiring commitment is a) a dangerous person requiring commitment or b) a person requiring commitment."

Leaving us with the first sentence: "... is a sex offender who suffers from a mental abnormality."

Mental abnormality is: a condition that "predisposes him to the commission of conduct constituting a sex offense and that results in his having a serious difficulty in controlling such conduct."

Which makes sentence 1: "a sex offender requiring commitment is a sex offender who suffers from a condition that makes him a sex offender." Which, of course, means anything you want it to.

II.

Douglas Junco was sentenced to 15 years for attempting to rape a woman because she gave him a ride home from a bar. After serving out his sentence, the state tried to civilly commit him further, but the jury refused to play along, so Junco went to Georgia and raped a 48 year old relative.

You'll probably want to say that he should have been civilly committed after all.

So what psychiatric testimony was presented to get him committed? The psychiatrist diagnosed him with:

Axis I: Impulse Control Disorder NOS.
Axis II: Antisocial Personality Disorder.

I will post a naked picture of myself punching a dolphin if anyone can tell me what the difference between those two diagnoses is in this case. Which one of these constitutes the mental abnormality? Explain your answer using evidence. It's a trial, right?

The judge:

...the court expresses its concern that although the respondent had been subjected to numerous psychiatric evaluations while in custody over a prolonged period of time (since 1992), he never was diagnosed with impulse control disorder NOS until the evaluation by Dr. Gonzalez on March 15, 2007. The court is further concerned that Dr. Gonzalez was generally not aware of the circumstances surrounding the numerous "tickets" issued to the respondent while in custody; that the doctor apparently gave some consideration to a criminal charge against the respondent in 1991 which was in effect immediately dismissed; that a determination had been made in a separate proceeding that as to the instant offense there was a lack of sexual contact; and, finally, that the doctor apparently was not provided with, nor did he therefore consider, any favorable reports submitted as to the respondent while he was in custody.
If you are thinking the psychiatrist didn't do a good enough job of presenting evidence to commit, you're missing the point. The psychiatrist did everything exactly the way every other psychiatrist does things, i.e. half-assed and disinterestedly. But that same evidence could easily have gotten a man committed forever. The reason he wasn't diagnosed with Impulse Control Disorder while in prison is because there was no external reason for the diagnosis. There were no services to provide or deny him on the basis of a diagnosis. And the reason Gonzalez did diagnose him with that is because that's what he needed for a commitment, in the absence of good stuff like psychosis. Expediency. It's that simple.

In addition to reviewing numerous documents and reports concerning the respondent, Dr. Gonzalez conducted a telepsychiatry interview of Mr. Junco which lasted approximately one hour. Incredibly, the doctor did not take any notes during the interview.
Incredibly? Your Honor, what was incredible is that it lasted an hour, and by incredible I mean completely and utterly impossible.

Again, to clarify: we're upset he didn't do a good enough job to commit, but a judge could easily have just taken the psychiatric testimony at face value and locked him and his mom and his fish and his car for a century.   The hoax is that there is any evidence to present at all. What evidence? What does a shrink know about future behavior, of human nature? I'm not saying intelligent things aren't known; I'm saying they are not more known by shrinks. Hell, why wouldn't you just ask other sex offenders for their testimony?

The reason this guy was able to get out and rape again is the same reason why other people who won't ever hurt anyone will be held indefinitely with no recourse: political expediency masquerading as science.

III.

Just a piece of advice. If you are ever arrested, make sure to ask for a jury. As for two juries. If your lawyer says the words "bench" and "trial" at any point in the same paragraph, flee to Argentina. Those 12 idiots, imperfect as they are, are one of the only things protecting you from a top down, hierarchical, classist, flow chart wielding government clusterfuck that has no time, interest, or money to deal with people as individuals, so it deals with them as groups, types, diagnoses and organ banks.

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===== ====== ===== The Last Psychiatrist: Obama And McCain On Mental Health Coverage
Applicable to their perspective on a wider range of issues.

NAMI released the results of their questionnaire to the candidates. Obama answered the questions (24 of them) while McCain sent a formal statement.

On the whole, neither response is heavy on content, but I made one interesting observation:

Obama: 2 out of 2000 words
McCain: 8 out of 450 words

the word "cost"

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===== ====== ===== The Last Psychiatrist: Observations Afterwards

the real test of your soul's strength is whether you are trying not to see it

As most know, I was the "victim" of a hold up of sorts, a "patient" came in with a gun and etc, long story short is I'm still here.

But I made some observations which are worth telling.

1. Despite spending almost 20 very personal minutes in the room with him, I cannot remember what he looks like. I know he's a male, I have a sense that he's about 6'1", and that he has dark hair, but... that's it. If he came up to me in the street and offered me a sandwich, I'd take it.   I know the hair was dark, but I can't remember if it was buzz cut, or short, or...

I can't remember what he was wearing. Blue and white shirt? Can't remember.

I do, however, remember his sunglasses, I can even remember a hair on one lens. The glasses were so prominent and unusual that they took my attention away from everything else, and, I reconstructed the physical appearance of this guy around his glasses. I believe that if he was not wearing those glasses I'd have remembered his face or his clothes better-- thought it's possible my attention would have been focused on the gun.
Now I know why they rob banks wearing Nixon masks.

2. As further evidence: I had his chart. I studied it after he was gone, and for sure I knew his name-- until Monday, when I discovered I had, for the entire last week, remembered his last name incorrectly. Not misspelled it-- completely a different last name. And when someone recently corrected me, I didn't realize I had made a mistake-- I was genuinely shocked to see I had memorized it wrong. I thought they were wrong.

There's been 20 years of good research on the (un)reliability of eyewitness testimony-- generally warning against the transference and distraction effect, and the universally terrible idea of offering a witness one suspect and saying, "is this your guy?"

Most have seen the gorilla walking through the basketball game video, but watch it again:

The problem is that our attention is weaker than our memory, and selective attention to one thing is at the expense of others. And no, it doesn't help that the girls are pretty.
Practice can mitigate this, but not extinguish it. And even someone like me who prides himself on his cool and his 133t perception skillz still gets tripped up. I'll repeat something important: I didn't forget his name, I really believed it was something else. I would have vigorously defended that belief. "Are you guys insane? You think I'd forget his name?"

3. I had wondered if, involuntarily, I'd be nervous to go back to that same office. Would I be hypervigilant? Would I have involuntary physical responses to the area? Would I dream about it?

No, none of those. When I awoke the next morning, it felt like it happened a decade ago. I went back like nothing had ever happened. I've really tried to understand why this is so I could propose it as a solution to other people who want to get past it, and what it feels like to me is that I was acting in a play a long time ago, playing the part of the doctor-victim, and now I'm onto a new role.
Reinforcing this is my feeling towards the guy with the gun: that if I saw him again, I wouldn't be afraid of him or even angry at him, but like he was an actor in a new role. Why would I not be afraid of him?
I've tried to parse this out, what allowed me to get over that so quickly, and I think I have the answer. Maybe this will help someone else.

4. What's my pivot point? What's the thing I keep coming back to, over and over?

If I run the fantasy version in my head, where I can imagine myself doing anything I want, the thing I do differently is I get the door open sooner. Whether I yell at him and he does it or he forgets to close it or someone comes in, the focus is that the door gets and stays opened. When the door was open, I felt like I was no longer under his control. That was the difference between having power and being powerless.
And so when I commanded the woman to get a copy of the insurance-- i.e. to open the door and leave-- and it worked, I had (perhaps the illusion of) power. He wanted her there, but I told her to leave, and he didn't stop her. I won that mini-battle. And even though it closed again and he remembered he was insane, when I run this over I am "proud" of myself for being able to control the situation and get her to leave.
So what it comes down to, at least for me, is finding the one specific moment where I exerted some power, where I was not powerless, and it made up for everything else.

Which explains the lack of hypervigilance or worry about going back: since I had some power the last time, I'll probably have some again. All of this may be an illusion or a psychic defense, but reorienting myself away from my powerlessness towards a single instance of power completely changed the emotional memory of it.

Results may vary.

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===== ====== ===== The Last Psychiatrist: Ocean Marketing Supports Obama

this better be worth it

What? Another catchy title that doesn't mean what it looks like it means? No, I meant it. If I had to guess I'd say Ocean Marketing actually supports Romney, but that doesn't change the truth of it.

For those who don't live on the internet: a customer service dispute ended up on the internet. The specifics are below, but they aren't relevant:

A guy pre-ordered an Avenger Controller from the manufacturer. It never came, so the customer complained. Ocean Marketing ran the customer service for the manufacturer, and Paul Christoforo was the contact person. The general form of Paul's responses to the customer were, "you're a jerk, I have no time for jerks." That may be a slight mischaracterization, but not really:

Buddy your asking for free stuff and I am trying to help you , You have no idea what happened to our ordering system or our old customer service reps that told you they were going to send you a 100% COUPON AND FREE CONTROLLER but never did . So calm yourself down , be respectful and do as I say or ask to get your free controller. I DEAD SERIOUS ! Be a little more humble we can refuse the right to ship out anything to anyone we want , I'm trying to help you. Small claims court for 49 dollars haha ... that's cute . I'm the President of my company not The Avengers so keep your punk smite ignorant comments to yourself. If I wasn't trying to help you I wouldn't have emailed you back. Customer service of old is gone were in a new generation now. Sorry for any inconvenience , this will ship tomorrow I'm putting in the order now .

The customer is only N=1, so he used the only power he had: he forwarded the emails to the the Penny Arcade guy, who also happens to own the entire internet. The result: it gets to Reddit, who send him thousands of emails, phone calls, outing him as a possible steroid user, discovering a police report of domestic abuse charges, etc.

He's tried to apologize, but his ego keeps getting in the way.

II.

There's one other thing you need to know. Paul Christoforo looks like this:

Paul's an idiot, and a bully. So what?

Paul appears like he's the bully because in that interaction between him and the gamer, he is. Additionally, he is pictured, in the mind and on camera, like a bully, and a jerk, and once you know what he looks like you can't unknow it. So it becomes impossible to judge him in any other way, which is bad for him and necessary for everyone else.

Here's what no one on Reddit seems to understand. To anyone not in the demo for an Avenger Controller, the Avenger Controller is a joystick. Which means that thousands of people ganged up on this guy, got him fired, harassed him, and potentially ruined his career-- over a joystick. I can see you want to interrupt me and say something about the principle of it, let me just say one more thing and I'll give you your time: to the United States government, it looks like the dangerous party is the internet.

Paul's a bully, but bullies can get bullied, right? Reddit just went Dylan Klebold on Paul Christoforo. Who is the state going to side with?

I ===== ====== ===== The Last Psychiatrist: Odd Finding of Gender Differences In Walking

A story about a study which claims to find a relationship between the perception of gender-- are the walking dots men or women-- and the direction those dots are going-- towards you or away.

I.

The story is easily summarized: researchers find that the perceived direction of motion is gigantically influenced by our perception of its gender.

Subjects watched "light point walkers," on a monitor, which have been standardized to exist on a continuum from extreme male to extreme female.

It is based on this computer model from this article. Play around with it.

Subjects uniformly identified the walkers as the appropriate gender. Interestingly, however, walkers judged as male were then judged to be walking towards them, while female walkers were judged to be walking away from them.

More interestingly, even when perspective information was added to the walker videos, it had no effect on perceived direction. Men were still coming, and women going.

This effect existed for both male and female subjects.

II.

It is "tempting to speculate" that this effect reflects the potential costs "of misinterpreting the actions and intentions of others," [study author van der Zwan] added. "For example, a male figure that is otherwise ambiguous might best be perceived as approaching to allow the observer to prepare to flee or fight. Similarly, for observers, and especially infants, the departure of females might signal also a need to act, but for different reasons."

Yes, it is tempting, in the same way it is tempting for evolutionary biologists to default to Lamarck when Darwin doesn't seem to fit the data.    As with all "cool" science, it pays to read the actual study.

Though not shown in the paper itself, the online version offers links to the videos themselves.

First, there were only five subjects, 3 women and 2 men. This is important because of my next surprising observation: am I insane, or does what they have labeled as "extreme male" look like a super sexy woman, and what they have labeled as "extreme female" look like a male Zinjanthropus?

mmc4.mov

mmc5.mov

etc. No, I didn't copy those wrong. There were several videos, and 80% of them looked (to me) to be the opposite gender of their label.   If these are indeed the videos watched by the 5 subjects, then it's not hard to see that not only is the study invalid, but those five subjects can never be called as witnesses.

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===== ====== ===== The Last Psychiatrist: Off Label Prescribing Turns Out To Be On Label
In which I bite down on a leather strap in an effort not to explode like that guy on Heroes.

An article in Pharmacotherapy that defies credulity. Really. Just look at me. I'm incredulous.

I. "These Drugs Are Not Indicated For The Following:"

The study seeks to examine off label prescribing so that further research into their efficacy and safety can be conducted. No word on who will be paying for that research, which, as I will now demonstrate, is completely unnecessary.

Here's the summary: looking at prescriptions versus indications, the authors found a list of drugs with substantial off-label use in the absence of substantial evidence for their use. One might ask whether the the substantial off-label use is in itself a form of evidence for its use, but we'll leave that for another day.

Here's the list.

IIa. I Thought It Was Indicated For That?

Right off the bat, you'll notice that Seroquel's most common off label use is bipolar, which is doubly wrong, because it is actually indicated for bipolar; and bipolar, not schizophrenia, is actually its most common on-label use.

Worse, this study is about use without "adequate evidence supporting its use" (look at the title of the chart.) So either these authors were completely unaware of the studies supporting its use and labeling by the FDA; or they were aware of it, and didn't think it was as adequate as the FDA apparently did. Either way, someone needs to quit drinking.

Next, While it is true that these drugs are being used off-label, they aren't being used off-label randomly. According to the study, Seroquel is used on label, or for the top three off-label uses, 77% of the time. Lexapro it's 98%. They're not using Seroquel for asthmatics. The issue isn't whether "depression" off-label use exceeds "anxiety" off-label use; it's whether there is any difference between either of those two uses. There isn't.

IIb. What Is An Indication?

For those who are not in the biz, it may surprise you to learn that the FDA does not decide what a drug is indicated for. It only decides if the indication that Pharma chooses to request is approved or not. If Risperdal is approved for bipolar mania but not maintenance, it doesn't mean that it isn't safe and efficacious for maintenance; or that there isn't a huge collection of data affirming this. It means Janssen didn't ask the FDA for the approval. In other words, 95% of the decision for an indication is made by the folks down at Pharma marketing. All the FDA can do is say yes or no.

And, as evidence, let me now say, categorically, that Risperdal will never get a maintenance indication. Not because it isn't efficacious or safe-- who knows?-- but because it's generic: no one will pay to get it approved.

III. "Oh, No, Doctor, You Need To Be Rigorous."

You'll notice a little superscript "a" which says that if bipolar was diagnosed along with mania or depression, then that wasn't counted as off-label. In other words, simply writing "bipolar" was considered off label? Yes.

But what about maintenance? Isn't it indicated for bipolar maintenance?

If you want to be technically accurate, Seroquel isn't indicated for bipolar maintenance-- it's indicated as an adjunct to lithium or Depakote for maintenance. How would the authors have known if it was being given with Depakote? They wouldn't.

You will notice, however, that Depakote is not on this list, despite it's not being indicated for anything except mania. All those Depakote scripts are all for acute mania? Wow.

(BTW, can you force Seroquel to be given as an adjunct to something else, when the somethiing else is itself neither approved nor effective? Hello?)

I'm splitting hairs, you think?   Nope. It matters, because this information found it's way into the news media:

From USAToday:

Seroquel, an antipsychotic approved for treating schizophrenia and short-term manic or depressive episodes in bipolar disorder, topped the list. Three out of four times, doctors use the drug off-label, mainly for maintenance therapy for bipolar disease, says senior author Randall Stafford, associate professor of medicine at the Stanford Prevention Research Center.

Got that? According to USAToday and Dr. Stafford, Seroquel isn't approved for bipolar maintenance. "Permission to get angry at Big Pharma?" "Permission granted. Fire at will."

IVa. There Is Method To This Madness

But arguing about the results of a study is freshman level sophistry. The real money is in the Methods section:

Question: How do they know what a drug was being used for, that they could call it off-label?

Answer: They took the data from a self-report survey of doctors. When he wrote "Seroquel" did he also write "bipolar?"

How do you know that what he calls "bipolar" is really bipolar? If he calls it bipolar, and uses Seroquel, but it's actually anxiety, is that on-label or off-label? According to this, it's off-label. So, in other words, on/off-label is defined not by reality, but by whether the doctor explicitly provides a label. Not whether he is right, but confident.

Then what prevents a doctor from simply writing bipolar every time he wants to use Seroquel?

Etc.

IVb. I Want To See This Self-Report Survey

If the lack of rigor in the psychiatric diagnoses isn't bad enough, how about this: how do you know the self-report isn't completely made up?

I don't mean made up as a "cover your ass"-- that the doctor writes "bipolar" just to justify his Seroquel; I mean that he completely invents the patient data?

I looked up their survey. Fortunately for me it's online; unfortunately for any doctor filling it out, it therefore takes forever to complete:

As you can see, there are three different screens: one for patient demographics (age, insurance, etc); another fopr diagnosis; and another for drugs. The doctor needs to type in the name of the drug, and also what he used it for. There is no accountability. There is no incentive to write "Major Depressive Disorder" or "Bipolar Disorder, Mixed state." You would simply write "depression" or "bipolar." Hell, there's not even an incentive to diagnose "obsessive-compulsive disorder" since "anxiety" would just about cover it.

Now go look at that superscript "a" and tell me if it's significant.

Also note that you fill out a whole new screen for every diagnosis (e.g. one for MDD, one for alcohol abuse, one for...) and each drug. Imagine you have 8-50 patients a day, two or three meds per patient (not including drugs from other providers for other problems that you are still responsible to enter), one or two diagnoses per patient...

All this might be filled out correctly, or it might not. Or maybe suddenly everyone got diagnosed with "MDD."   Maybe everyone got "effexor" but not "effexor xr." There is no way of knowing.

V. Are You Saying This Study Is Invalid?

Unreliable diagnoses; unreliable application of those diagnoses; and unreliable self-report of those unreliable diagnoses that were unreliably applied, along with unreliable report of the medications used. Peer review x 3, and publish.

But don't run off just yet, Ironman. This doesn't mean that this particular study is invalid. It means all studies based on psychiatrist self-report are invalid. All of them. Write that down. All of them.

VI. "You're Being Unfair."

"But just a minute, Dr. Pirate, you aren't being fair. Seroquel received approval for bipolar maintenance in May 2008. The study used June 30, 2007 as its cutoff for FDA approvals."

Yes. That's not suspicious to you?

And even if that was an accident of history-- the study was completed before Seroquel got the maintenance indication-- why wouldn't they go back and revise the manuscript which was published only two weeks ago? Wouldn't you at least mention this new development in the news interviews you gave? This is supposed to be science. Do you allow the publication of a study when you now know that the main result of your study is wrong?

You know, so as not to look like you're purposely generating a negative article about something which you now know to be untrue?

VI. Who Was This Study For?

It's for politics, of course. The study is published in Pharmacotherapy so that it can be written up in the Wall Street Journal, or USAToday; so that they can be interviewed. It is a MacGuffin. Doctors aren't reading it, the public is reading it. It's war by other means.

It also shifts money around, the historical purpose of government. It sounds the alarm of too much spent on marketing, too little on safety and efficacy. In the era of bailouts, this is an excellent position to take.

===== ====== ===== The Last Psychiatrist: Ohio Mom In Jail For Sending Kids To The Wrong School

collateral damage

A (black) woman pretends to live in another school district to be able to send her kids to that better school. She gets caught, and is sentenced to jail.

The question on everyone's mind is if/how this is unfair, but the real money is in another question: why now?

We can all agree: if they wanted to handle this quietly, they could have. Prosecutors could have easily turned this into a misdemeanor, let her plea bargain.

Instead:

The district hired a private investigator, who shot video showing Williams-Bolar driving her children into the district. The school officials asked her to pay $30,000 in back tuition. Williams-Bolar refused and was indicted and convicted of falsifying her residency records.

Re-read those three sentences, but put the word "Then" in front of the second and third. Oh, so that's how it is.

The wrong way to understand this story is to think it is racial (which it probably is), or that she deliberately manipulated two systems-- public housing in Akron and schooling in Copley-Fairlawn (she did.)

The important points not in the news: she had been pursued by the school district for years about this, as had other parents gaming the system. So the question is why they indicted her in November 2009. Not why her; why then.

II.

Here's the first hint that this "news story" has nothing to do with conveying information to you. Look who gets a quote: prosecutors, superintendents, judges. Look whose name is completely absent: her lawyer's. In fact, that she even had a lawyer is not mentioned once. I'm sure she had one, but what he had to say isn't important to the story... is it?

The missing part of the story is that in November 2009, the district was about to lose $467087 due to Ohio's inability to balance their budget. On August 3, 2010, the Copley-Fairlawn district was the only one of 7 districts that managed to pass a school tax hike of 23%.

The board chose to pursue this woman-- apparently, the first one so prosecuted in the state's history-- for the specific reason that it can. It is a display of power, a show of force: we will protect your interests. If you're asking why her, you're missing the point, it could have been her for a million tiny reasons: race, she had been antagonistic with the board in the past, she was left handed, who knows? This wasn't an assassination, it was a bomb blast. She just happened to be in the building.

Why are you hearing about this story, in this way: "oh my god, those bastards won't even cut a break to a poor black woman?"   Because that story simultaneously delivers the government's message: "we don't squander taxpayer resources; we'll fight to protect every dime we can get." The symbiosis between media and politics: the media gets their readers, and the government gets their message relayed to the public. There's no news here, this is propaganda.

"But why would the school district want to portray themselves as racist meanies?" Do you think they care what you think of them? Dolla dolla bill, y'all. They owe their allegiance to the voters of Copley-Fairlawn.

"But what's wrong with the Board protecting taxpayer money?" That's just the point, they're not protecting it, they are pretending to protect it.   $30k for two years and two kids? If you think the cost of public education in Akron is $7500 a year, you are completely and utterly insane and need to be disintegrated with acid. The University of Akron, which is only slightly worse than any high school in Akron, charges $8k. Granted, their teachers have PhDs but,... wait a second...

$30 million budget? For what? As long as you assume they're racists, as long as you think they are way too strict in their pursuit of fraudsters, then never will it occur to you to ask what exactly you're getting for your money. That's what the media is for. Oh, look, Idol is on tonight.

Anyone on the outside should be able to see this for what it is: a mafia style protection racket. Pay us. If you pay us, we will protect you from those who... don't pay us.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Oh, Please, What Do Europeans Know About Psychiatry?

I mean, like, don't they have seven month vacations over there? And state sponsored affairs?

The prevalence of bipolar disorder in kids is considerably higher in the U.S. than in Europe.

Why? Either American kids are more whacked then Europeans-- and you can blame genetics or environment for this; or, the process of diagnosis is whacked, either here or abroad. Go on, pick: Tatooine or Hoth.

One way to answer this is to use American style diagnostic tools, such as the NIMH's Child Behavior Checklist (CBCL), on Europeans. The answers on the CBCL can be grouped into different profiles, relating to different diagnoses. For example, elevated scores in certain areas gives a CBCL-pediatric bipolar profile.

Using this approach, we were in fact able to show that the prevalence rate of children meeting this profile in Germany was comparable to pediatric bipolar rates in other countries using different diagnostic approaches.

In other words,

The prevalence of CBCL-pediatric bipolar disorder subjects in the general German population compares to rates of pediatric bipolar disorder in the US...

...However, no patient [with the CBCL bipolar profile] received a diagnosis of bipolar disorder. Instead, 3 of 4 children with this profile (whose conditions would presumbaly have been diagnosed as bipolar disorder by some colleagues in the U.S.) received diagnoses of ADHD, oppositional defiant disorder, and conduct disorder.

So there you have it: the diagnosis is whacked.

Ah, you say, come on, what's the difference what you call it?---

Regardless of whether these subjects are affected by 'real' pediatric bipolar disorder or 'severe, pervasive ADHD' [etc]... they constitute a group of seriously disturbed children and adolescents.

Yes, but even though the world agrees the symptoms are the same, the consequences of each label is very different, right? The epidemiology, the prognosis-- the meds?

But the real difference is the societal implications. Getting a diagnosis changes the way you relate to the world, and the world relates to you.   The label changes your identity and how you think.

Don't agree? Try killing someone and using "pervasive ADHD" as a defense. Get it?

We pretend that psychiatry is an emerging science, and hide behind a feigned ignorance ("we don't know everything, but we're making progress!")   And so no one has to take responsibility, or even admit, that psychiatry is changing the evolution of humanity, right in front of our eyes, with nothing more than words.

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===== ====== ===== The Last Psychiatrist: On Being White

Is there anyone who can speak frankly on matters of race? Yes: Louis CK.

If you haven't heard this before, pay close attention to your reaction to this clip; and then pay even closer attention to how it does/does not change at 1:30. Also think about how this would all be different if you were surrounded by whatever race you're not.

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===== ====== ===== The Last Psychiatrist: One Last Word on University Suicide

Good debate going on over at Shrink Rap.
I've posted a few comments there, but in summary:
Hunter College didn't expel her for being suicidal; they EVICTED her from her DORM for ATTEMPTING suicide. They wouldn't be allowed to do the former; they are obligated to do the latter, for public safety.
People want to refer to the George Washington University case. Ok, but let's get our facts straight, from the Superior Court:
Jordan Nott's roommate jumped out the window OF HIS DORM in April 2004, while Jordan and a friend were trying to break in to save him. In October 2004, thinking about this, Jordan himself became suicidal but went to the ER instead.

The University suspended him. Well, not exactly:
in order to be “cleared” to return to the residence hall, the UCC and Community Living and Learning Center (“CLLC”) had to assess Jordan’s “ability to obtain recommended treatment” and ability to “live independently and responsibly.” In order to obtain clearance, Jordan had to set up an appointment with UCC within 48 hours, and develop an agreed-upon treatment plan."

That's not GWU's defense-- that's Jordan's complaint. That he had to go through that. Is that so unreasonable?

Living in the dorm is a privilege, not a right. If the University thinks you are a risk AND it doesn't violate constitutional rights, you're gone. It's not up to them to prove you are a risk; it's up to you to show you aren't.
And people are angry about GWU and Hunter because it seems that they're just out to minimze their liability? Yeah, so what? And it's not just the liability of student who kills himself. It's about his effect on public safety.   People say that an OD or jumping out a window doesn't put other students at risk. Well, clearly Jordan's roommate's suicide had an effect on Jordan-- he admits this himself. So there's the copycat risk. And what if Jordan had decided to blow himself up? Why should anyone in the dorm have to live with that risk?
Again, it's not up to the school to show she's dangerous; it's up to her to show she's not.

The best line is this one:
If he had known [about the evictions, etc], he said, he never would have gone to the hospital.
So what are you saying? That he would have simply killed himself?

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===== ====== ===== The Last Psychiatrist: One Of These Things Is A Straw Man, And The Other Is On Fire

Daniel Carlat, of the Carlat Report, has an article in the New York Times Magazine. It's six pages long, and decidedly anti-Pharma. But Daniel Carlat isn't from New York-- so why would he have an article published there?

You say: well, where he's from has nothing to do with it, the New York Times is publishing it because of what he says.

Exactly.

His article, well written and persuasive, stands as is, undisputed because there is no forum in which to dispute it. I guess it would be nice if the Times would allow me to write an op-ed-- you know, in op to the ed-- but I guess this blog will have to do.

Carlat is wrong, very wrong, not because he is factually incorrect about his target, but because his target is a straw man. The problem isn't Pharma. It's doctors.

The article, called Dr. Drug Rep, chronicles his introduction into the world of lecturing for drug companies-- a company hires you to give a talk about a topic or drug to a bunch of doctors-- and the effects of the lecturing on doctors and himself, and then his pulling out. For context, Carlat is a fairly famous psychiatrist blogger who is both a sort of watchdog of Pharma, as well as a source of information about psychiatric drugs.

The general message is that Pharma softly manipulates doctors to act as proxy drug reps, which in turn lends credibility/celebrity endorsement to the Pharma message, and thus influences other doctors to prescribe the medicine. Ok, I hear you. I have no beef with Carlat, his point is not unique.

But break it down:

So we don't want doctors lecturing about the drugs. Okay. Well, who do we want? More reps? Here's where it all falls apart, and I defy anyone to contradict me: doctors aren't studying these drugs on their own. Doctors wouldn't know anything about the medicines if it were not for Pharma and its tentacles (reps, speakers, drug company research and publications, etc.) Carlat himself has written extensively about the supposedly objective "Continuing Medical Education" process being a Pharma -sham. (Not to mention horrendously useless.) There is no objective education in medicine. None. Stop pretending there is.

If you want evidence of this, consider that the despite the cardiac risks of Vioxx being publicly-- as in Yahoo! News publicly-- known even in 1999, doctors were surprised when it was pulled. "What? They never told us about that..."

And don't tell me there are journals. They're worse than literary quarterlies, and no one reads them anyway. Don't believe me? Ask your doctor to name one single article in any of this month's journals. Not if he read it; just the title.

You say: well, we don't mind the lectures, per se, we just want them separated from Pharma money. Oh. Whose money do you intend to use?

There's a bit of a misconception about what goes on in these lectures. A doctor doesn't stand up and say, "I've used Effexor, and it's awesome. Way better than Celexa. Which kills puppies." They actually have to use an FDA approved slide deck from which they cannot deviate, even if it's a fact. For example, you can't say the following sentence: "There was a study published in the New England Journal..." unless the FDA allows you to say that. And doctors are obligated to give "fair balance," which means you must talk about the risks as well as the benefits. Risks which are prominently featured on the slides.

But that's besides the point. I am not an idiot, of course, and I understand marketing and how to lean a lecture. But let's be rigorous. These lectures are intended to get you to prescribe Zoloft over Prozac, not over penicillin. If I'm "influenced" to prescribe Zoloft instead of Prozac, what's the harm? Not in theory-- in actuality. Tell me when Zoloft is inappropriate that Prozac is appropriate. And if you do discover such a mythical patient, then my choosing Zoloft for that person isn't a case of Pharma manipulation, it's a case of me sucking as a doctor.

The simple problem is that it sounds really bad to have Pharma be so much a part of medical education. And it is, but there's no other system in place. If today you fire all drug reps, then you will effectively freeze medical care to November 2007.

Because there is no "objective" system for evaluating and disseminating information, the only way to form an educated opinion is to listen to the different pitches and stories and parse out the truth. And Pharma is very good at this: Zyprexa's diabetes risks were first popularized by Pfizer, who were defending against Lilly's attack on Geodon about QTc prolongation.   (And don't think for a moment doctors would have figured out QTc risks on their own.) I think it would be great if academics, or some objective body, could be in charge of this, and in charge of publishing their findings, but this doesn't exist. It would be great if legal issues could be resolved "objectively," too. Wish it all you want; that system does not exist, all you have to work with is this the Pharma adversarial system. That's it. You know what a Pharma free system looks like? Cuba.

Pharma is the backbone of medicine, because, unfortuantely, medicine is about treatment, not prevention. If a doctor recommends exercise, or garlic, or even aspirin, it's a sidenote, and a quaint one. "Oh, my doctor thinks I should move to Florida for my asthma!" Meanwhile, they'll give out the amoxicillin to every crying toddler, even though they know that that is detrimental. you know why? Because it looks like a treatment.   It's not all the doctors' fault; but that's the system.

I'm going to repeat this because I know people are going to misunderstand me: the system that you want is impossible to construct in the framework of modern medicine, if for no other reason than doctors don't read-- derive no benefit from reading. The system does not exist, and you cannot create it. Psychiatry is politics; medicine is the justice system. Pharma are the opposing lawyers, and doctors are the jury. The jury must decide the fate of the defendant-patient. And the FDA--judge simply makes sure everyone is civil. Not accurate, save for outright perjury; just civil.

Does this scare you? Me, too. But that's the system. Learn to work in it.

I should mention that this system is the only one that allows the public-- patients-- access to the information. In a closed, hierarchical system free of Pharma marketing, patients would have no choice but to completely trust their doctors to know about the medications. Think about that.

A strange part of all of this is that the target "consumer" for Pharma is doctors; those are the people we want to protect from drug company influence. But doctors are the most educated consumers anywhere; if they can't separate truth from marketing, what hope does the Chevy Truck demographic have, who hear about no money down? Do we ban all advertising?

Blaming Pharma is a diversion. It gets the world distracted from the real issue, which is that medicine is set up-- incentivized-- for mediocrity.

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===== ====== ===== The Last Psychiatrist: One Should Note...

... that these are the same.

So much easier for the government if they could put the two together.

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===== ====== ===== The Last Psychiatrist: One Way Our Schools Are Training New Narcissists

let someone else play on it

A bunch of first grade boys and girls were playing soccer at recess. One boy, Devastator, was particularly aggressive and slide tackled two kids. The playground rules is, "no slide tackles."

On the third slide tackle he hurts a boy who starts to cry. Devastator laughs and says, "sorry fucknuts, no crying in baseball!" and runs off. He is wearing goalie gloves. A girl says, "hey, no slide tackling-- you're going to hurt someone!" Devastator spits on the ground, comes over, gets right in her face, puts his fist up against her nose and says, "you better go back to where you came from, or you're going to get exactly what's coming to you." I don't know who taught this kid to talk. I assume TV.

The game immediately resumes, no one challenges him. Soon, he slide tackles another boy. The same girl, in defiance of Devastator, yells, "hey, no slide tackles!"

Devastator approaches slowly to close the distance, then suddenly sprints towards her. Another boy just manages to grab a shoulder but can't hold it, so he slows Devastator down for only a second, but long enough for the girl to get a head start running. He chases her-- she runs to the teacher and he quickly doubles back to the soccer field.

The girl tells her story, and the teacher responds, "just don't go near him. I'll talk to him. Go play a different game, I don't want him hurting you."

Later, the girl tells her mother, who calls the school. The teacher tells the mother that they have had a lot of trouble with that boy already, they are handling the problem, but in the meantime it's best if the girl simply stay away from him. "She was really brave, but we don't want her to get hurt or for him to fixate on her, so it's best if she stays out of it."

II.

Bullying? Or regular playground stuff?   You can New York Magazine this story and say that Devastator is carrying around a lot of anger and the school needs to intervene. If he's willing to threaten a girl and then actually try to attack her, he's destined for trouble and a full Nautica wardrobe. Is this what we want?

If that's the magazine you like, then you have to wonder if the school is really doing enough to protect her and the others? And what's their policy on violence towards women?   If the girl hadn't said anything, would he have gone unnoticed only to date rape a 3rd grader?

But Devastator isn't the important person in this story.

This girl stood up to the bully not to protect herself but for the sake of others-- and rather than supporting this behavior, the school crushed it in the interest of expediency and "safety."

If there is any value you do want to encourage in kids, it's looking out for each other. The girl had it; the boy who tried to snag Devastator also had it. Those were reflexes, they didn't plan this out over morning waffles, but whatever was going on at home and in their heads lead them to have, and to follow, those impulses.

But the school fostered the reverse value: "don't get involved, take care of yourself, let the Watchers handle it. That's their job." Note that the school didn't inadvertently teach her not to look out for others, it specifically instructed her not to look out for others. "We'll handle it."

I'm not saying she should have fought him (and I'm not not saying it, either), but what kind of school doesn't want a kid to stand up to a bully, especially when they're doing it to help someone else? What kind of crazy school wants you to back down-- and get someone else to protect you? What kind of school indoctrinates kids that power is only possessed by a) bad people; b) the state?

Oh. All of them.

---

http://twitter.com/therlastpsych



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===== ====== ===== The Last Psychiatrist: Or, You Could Just Nuke The Bitch

no, i was just giving him a boost

This is how it happened.

She's zippering the coat of her 6 year old son after soccer practice. Two other mothers are talking nearby, one of them animatedly, about how some bastard kid punched her son. "No one hits my son.   If I find that mother, I'm going to let her have it."

She finishes zippering, gets up, and they walk to the door, but she hears Angry Mom yell to her. "Hey!" she says, coming towards them. "I want to talk to you."

"Me?"

"Yeah, you. Your son punched my son." She is very angry. And loud.

"He did?"

The background noise in the gym goes down as all the mothers stare openly at the confrontation.

"Yes, "says Angry Mom, "he did. Scratched him right in the face."

She looks down at her own son. "Is this true?"

He looks up at her. "No, I didn't hit him."

She looks back at Angry Mom, tentatively. "I'm sorry, there must be some kind of mistake, are you sure it was him? He doesn't hit people, he's not that kind of a person."

"Are you calling me a liar?"

"No! no, I'm just saying that--"

Angry Mom calls over her shoulder to her own son. "Did this boy punch you? Don't be afraid, you tell me."

"Ummm, yes."

"I'm very sorry if he did," and then turns to her son, "are you telling me the truth? Are sure you didn't hit him?"

"No, really, I didn't."

"I'm sorry, I don't know what else to do, he says he didn't do it and I know him, he's not that kind of boy."

Angry Mom cuts her off. "The coaches are going to hear about this. I won't tolerate violence."

"I'm sorry--"

END SCENE.

The mom walks away shaken, for two days she can't get past it. That kind of emotional hysteresis happens to all of us, and if the reason for it isn't actual guilt then it's repeatedly trying to force an incorrect interpretation onto a situation. For the right one, you have to look at it from the outside.

Re-imagine this as a scene in a movie. What is the setting, why is it there and not, e.g., over the phone or in a private meeting with the coaches?   Who is (singular, not plural) the main character?   Who are the supporting cast? Who are extras, and what are they for?

Dialogue like this is exposition. What does it tell us about the characters?

II.

It may seem that Angry Mom is angry because her kid got punched, but she was actually Angry before that. Allow me to explain.

In this scene, she's yelling at the mom for two reasons, both of them bad.

First, because in America you NEVER yell at another person's kid-- or praise them, or hug them, or ask them what their favorite Harry Potter movie is; every adult-child interaction is immediately interpreted on a continuum of pedophilia or abuse. (Why are we so worried about child abuse nowadays? Because the truth is deliberately obfuscated. CNN will tell you how many pedophile priests there are, but not emphasize that they molested 20+ years ago, and that the incidence of priest-abusers now is tiny. Nor do they let on that they know that the person who molested you almost certainly has the same last name as you, BORING, here's a modified narrative about a girl we'll call Elizabeth Smart. See? It was a crazy person, and they're everywhere. The state encourages the media promotion of boogeymen-- in the 1970s serial killers, today pedophiles and etc-- because it makes the populace demand increased state control in their private lives, which is the precisely the natural single goal of any state. The state and the media effect this encouragement by pretending not to know of the boogeyman's nonexistence.   Says a Congressman: "you mean there's an epidemic of baby rapers out there? Wait-- did you say rapers or rappers? The hell you say! Elect me, I'll make sure we buy thousands of cameras from my supporters at Nikon to monitor our streets, we're going to need tech support so let's bring in Google...." None of this is consciously planned in advance, it doesn't have to be, it is in the nature of things: individual selfishness always finds a way, and that way leads to indoor recess for all of us.)

But she really doesn't want to yell at the kid, the point is to yell at the mom, that's the whole reason for this exchange. The kid isn't a person, he's an extension of the mom, in the exact same way that Sarah Palin isn't a Republican but an extension of the Republican Party, which is the only reason you're yelling at her.

Second, she's conveying to the audience that she's the kind of mom who defends her kid, who is tough, who will stand up to anyone. That's the reason she was telling the other mom about it and why the confrontation is so public. Does this exchange say, "don't mess with her kid?" No. It says, "don't mess with her."

III.

What about the puncher's mom? Surely she is not at fault?

Well... her mistake, a crucial one, is she allowed herself to get blindsided by the Angry Mom's Cognitive Kill Switch-- hijacking a discussion and making it a criticism of the person's identity instead of the actual issue. Rather than repeated I'm sorrys and he's not that kind of boy what she should have said is, "why are you yelling at me? I didn't punch your kid."

That changes the whole movie, now we have a different main character. Now Angry Mom is put on notice: back off and let's talk rationally, or confirm to me you are a nut and face the consequences.

But her reflex-- a product of the generational forces to which she was exposed-- was to square off and get defensive: my kid wouldn't do that, my kid wouldn't lie. She accepted Angry Mom's premise-- the premise of Gen N-- that the kid is only her, and so she took the Angry Mom's attack as an attack on her directly, which it was, because that's the premise. If the kid is truly an individual, he has to answer for his own behaviors; and not just explicitly, but implicitly: if the mom's reflex is defensiveness then the reflex isn't towards individuality.

This is a kid who has a brain and does stuff, yes, a lot of it involving boogers and punching but still he is the one doing it. But the two moms are treating it like a fender bender: you lost control of your kid and drove him into my kid because you were too busy texting, and that makes you a bad person.

IV.

But why isn't this just a case of a mom reacting angrily to her son getting hurt? Why can't it just be that she wants to protect her son? Because the prepositional phrase is absent: protecting him from what?

I said this was a scene manufactured by Angry Mom to display her identity, and as incorrect as that analysis might initially feel you should consider it very seriously. If the purpose of the confrontation is to prevent her kid from getting punched, it failed. Will it prevent another kid from punching him? Will it prevent even that boy from punching him some other day?

It is completely impossible to expect that boys are never going to come into violent contact with each other. It is simply unnatural. I'm not talking about bullying, but any two kids who are otherwise friendly are eventually going to punch each other in the nuts. And then go right back to playing Madden. God made them that way. Sure, break it up, sure, reprimand them, but if kid A hits kid B, then the situation is kid A hit kid B, not "I don't allow violence in my home."   Zero tolerance is impossible and counter to the education of children: it teaches that violence is the sole privilege of the state and the people who run it.

V.

Does it seem like we are hypersensitive to kid on kid crime?

Call it PTSD By Proxy: a bully of your kid is a flashback to being bullied yourself, and what you wish you could have done had you been bigger and more powerful and, hey, wait a second, you are bigger and more powerful. But as much as you'd like to travel back in time 30 years and be an adult kid again so you could punch your son's bully in the face, you can't because he wasn't alive then and he didn't bully you, he bullied your son, and he's a kid and you're not. So all you can do with that rage in a Tardis is yell at the other parent, or bully the bullies using the weapons you have, like laws and rules and social norms, and if you cross the line I am going to make you regret it.   And if that logic seems highly convoluted, well, Seroquel isn't a blockbuster for nothing.

VI.

So if a crazy parent rolls up on you, what can you do without resorting to a tire jack or 20oz Dunkin Donuts stun grenade?

You don't let it be about you.

The first step is to make the other person feel important, that she has been heard. She's upset, so you assure her that you're going to take on her level of intensity to handle the situation, you will make it as much of a priority for you as it obviously is for her: "Listen: I'm going to get to the bottom of this. If my kid actually did this, then don't worry, I will go old school on him, and he'll come in tomorrow with an apology and an offering of Junior Mints." You don't have to accept any blame, but you can't just deny it and trivialize the other person's complaint. No parent wants to feel stonewalled. Even crazy people want justice.

Simultaneously, you have to declare the limits of your deference, that the only reason you are not going Defcon 2 on her is that you are reasonable. "...but, if it turns out that he didn't do anything, well, we're just going to have to let that be the end of it. Right?"

Finally, in every conflict, the ones you can win and the ones you can't, unless you really want to fight you must always give the other person a saving-face way to back down. No one, especially nowadays, wants to walk away in shame, they'd rather die, or kill you. Angry Mom stupidly made this public, and so she has no way to back down unless you, as the more powerful person, the one with understanding, give her one.

You take the conflict out of the interpersonal and move it to the realm of fairness and justice promising to abide by whatever comes about.

And yes, I am talking about Iran. Bet you didn't see that coming.

---

You might also enjoy:

Why Parents Hate Parenting

When Was The Last Time You Got Your Ass Kicked?

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===== ====== ===== The Last Psychiatrist: Osama Bin Laden Has Been Killed

but he says...

Early Monday morning I heard the news: "Navy Seals have killed Obama." Ha. I knew what they meant.

The view from my chair: my very first thought was that this was a scam. How convenient. Any pictures? No. Video? No. Body? No, that was dumped in the sea. Sea? What sea? Pakistan has a sea?

The more I watched the various news anchors gloat about Obama and the Special Forces and "the turning point in the war" the more I became convinced I was being lied to. I've seen Fog Of War, Network, Three Days Of The Condor and Independence Day and I know a long con when I see it. Unless I could see the imprint of the bullets, and put my finger into the wounds, I wasn't going to believe it.

But something nagged at me. Why was I so suspicious? Why did I need to see the body for myself? What was it that made me think there was something deeply wrong with the story I was being told?

And then the answer hit me: I drink too much. Rum. And I don't sleep. I'm also not a very good person.

Did I really need to see the body to believe he was dead? It was information bias supercharged with arrogance: I'm going to be able to tell it's him? Me? Really? Forget about CGI and make up and look alikes-- they could show me a picture of a female puma and say it was bin Laden and my only contribution would be, "damn, dialysis is hard on a mofo."

II.

The first step in recovery is admitting you have a problem. Ok, I have a problem, but it's not all my fault.

It's impossible to hear the news about his death and not feel some sense of payback; but it's also impossible not to hear the news reporting and not want to punch something electronic.

None of them reported the story. I don't just mean how much they got wrong, I mean every one of them used it as an opportunity to explain how awesome they were.

Some examples, not too many, you need your strength:

Start with the media outlets and politicians that were fooled by the fake bin Laden death photo. I'm not concerned that they were duped, fine, female puma, but I am very concerned that they didn't google the photo to see if it was a fake?

Congressman Scott Brown said, "Let me assure you that he is dead, that bin Laden is dead -- I have seen the photos."

Ok, so he was fooled, fine, the guy doesn't work for Adobe. But why did he then say about the photos, "If it's to sell newspapers or just have a news cycle story, no, I don't think they should be released." What? How did he see them, remote viewing? He saw the photo on the internet just like everyone else-- or does he think he has a secret internet? Actually, yes: he saw them on his Blackberry, which is totally different.

What this shows you is that there's an airhead gap between politicians and journalists and the rest of humanity. They have not yet connected the world of the internet with their own world; yes, they're aware their internet is the same as ours, but they think they're seeing something we can't see by virtue of who they are. They're privileged. And they're going to remind you of that special privilege every chance they get, which is why you see so many news reports about news reporters.

I'm exaggerating? This is what Scott Brown then said, out loud, to people with microphones:

[President Obama] made the ultimate decision and he made a bold decision. I have a handwritten note to him to that effect.

That's where his head is at. Bin Laden is dead, and he is bragging to the press about a note that he wrote.

The myopia isn't exclusively self-aggrandizing; sometimes it's just ignorant. This morning, Senator Schumer was interviewed on CNBC "live at the WTC site."   As he's crowing about "yes, we have increased electronic surveillance but there hasn't been another attack," he adds, "remember, right after the attack we were all worried this area would become a ghost town. Now look at it... young people are moving into high rises." Do you see? He thinks the young people are finally over their fear. But those young people were in high school when 9/11 happened. They're don't remember it as "yesterday," it was two lifetimes ago, and right or wrong they're not afraid of "another attack" in the way a 40 year old is. Do you expect a person who has no intuition about "young people" to be able to think long term, for the benefit of three generations out? If you show him the digits "2097" he gets vertigo and falls down.

III.

Over at basic cable the Mayan Calendar was coming to an end.   CNN jumped at the chance to offer breaking news-- about which they had no actual information, much like its reporting on 9/11. But you have to fill the time; so they ran a seven page story, only three sentences of which had anything to do with bin Laden's death. CNN did, however, make up for it by running a poll:

Do you think bin Laden is in Hell, or don't you think so?

a) in Hell
b) not in Hell
c) don't believe in Hell
d) not sure

It's been a long time since I infiltrated IVCF to penetrate a girl, but isn't publicly answering this question in the affirmative 1 Cor 4:5 proof that you lack God's grace? I'll save you the look up: yes.

Fox News was in a full blown existential crisis: "yay he's dead! Whoa-- son of a bitch, Obama gets the credit?" It was as like a man thrilled that he finally got his hot wife to have an orgasm, but unfortunately it was by letting a black man have sex with her. That's right, Fox News is a cuckold. They dutifully gave Obama credit for "giving the order" but reminded everyone that it was Bush era policies (and later waterboarding) that gave us the intel. See how I said intel? That makes me sound smart.

Jon Stewart isn't a news guy. I know this because he keeps telling me he's not a news guy, yet 1.6M people get their news from him and there's is no detectable difference between him and Keith Obamaman. Here's what Jon Stewart said:

Last night was a good night, for me, and not just for New York or D.C. or America, but for human people. The--

Stop the tape. Nobody move, stop, have a drink, I insist you really meditate on the enormity of this man's monologue. Why is it such a good night? It has to be duh, right?

The face of the Arab world in America's eyes for too long has been bin Laden, and now it is not. Now the face is only the young people in Egypt and Tunisia and all the Middle Eastern countries around the world where freedom rises up. Al Qaeda's opportunity is gone.

Ad hominem is not my style, but here it can't be helped: this man is an idiot. This is what he wants us to believe he believes? Right before he closes his eyes at night he says to no God, "phew, now Americans can look at Arabs more realistically?" Never mind that who he thinks "the young people in Egypt and Tunisia" are bears no resemblance to actual young people in Egypt or Tunisia or anywhere on the planet except his audience, none of whom are in Tunisia, and none of whom will every rise in revolution to fight for freedom, ever. Not unless Steve Jobs tells them to.

The whole thing, from the politics to the news reporting, is set up not for the conveyance of information or truth but of image and feeling.

IV.

In this content vacuum, in this total avoidance of substance in order to project personal image, how can anyone be faulted for not reflexively distrusting everything they hear?

It doesn't help that the government and media want me to believe it's not staged, that they wouldn't stage it, even as they stage stupid things that don't need to be staged. When you watch the President give a speech, you're watching him give a speech. When you see a photo of him giving a speech, you are seeing a photo of him re-enacting the speech he gave-- just for the still cameras.

"No, you're misunderstanding. It's not a great system, but the cameras are too loud to use during the actual speech. There's no other way to get the photo." No, you're misunderstanding: no one cares about the photo. Do you really believe we want a fake photo of an event you couldn't attend? Oh.

V.

And then there were the slips of the tongue:

"Obama has been killed in Pakistan."

"President Obama is dead."

It happened enough times for it to be significant, and, as usual, significant in a way that the media missed.

What everyone wanted it to be was evidence of a Freudian slip: an unconscious desire pushing itself into verbal expression.

But that's not what a Freudian slip is, really. A Freudian slip serves the purpose of discharging energy, either anxiety or desire, whose origin is unconscious. If Blake Lively is nude and says, "would you mind helping me get dressed?" and the guy responds, "oh, sure, I would love to bone you!" that's not an unconscious desire, that's a perfectly conscious desire that he accidentally said out loud. If he says it, the unconscious slip isn't that he wants to bone her, but that he wants to tell her he wants to bone her. In other words, he's scared of her; the slip discharges that anxiety.

Substituting "Obama" for "Osama bin Laden" is straight up cognitive psych, yo. Substituting a less common word for a more common one is a Freudian slip; a more common word for a less common one is a problem choosing what word to choose for a linguistic unit.   Not

"<man> is dead."

but

"<word for arch-nemesis or bad guy> is <word for expired>."

In the Mad Lib that is his brain, "Obama" is more accessible for "bad guy" than "bin Laden." I'll let you work out the implications.

VI.

What's going on that people are so suspicious-- or so sure-- just because it happened during Obama's Presidency?   Grant me that you stick Bush in there, and everyone switches sides.

"People have good reason to be suspicious, the government has a track record of lying to us." Agreed. And I don't need to be reminded that Afghanistan has a trillion dollars worth of precious resources like lithium and adamantium that we'll need for future facebook phones. They can't tell us they want that, so they pretend it's for something else. Right?

But the practical problem is that when we are forced to divine the "real" motivations for politics that changes the behavior of the politicians in unexpected ways: it doesn't make them less likely to wage war for oil and say it's for democracy; it makes them more likely to do it in secret. Hence your new CIA Director, supporting mercantilism one special op at a time.

This is the pattern of abuse. Your father is manifest superego, if he tricks you or hurts you enough and you don't trust him anymore, ===== ====== ===== The Last Psychiatrist: Parenting and Personality Disorders

A fascinating article that no one will ever actually read: Parenting Behaviors Associated With Risk For Offspring Personality Disorder During Adulthood.

The authors made a (startling) discovery: there are types of parenting behaviors which predispose your kid to growing up personality disordered.

This was a longitudinal study of 592 families, first assessed when the kids were about 5, and then again when they were in their 30s.   (More info at their website http://nyspi.org/childcom/)

The results are pretty much what you'd expect:

The more of these behaviors the parents exhibited, the more the risk of PD increased.   What is interesting is which PD was increased given the number of parental behaviors:

First, overall number of bad parental behaviors:
(antisocial=criminal; avoidant=shy; narcissistic=self-absorbed)

You'll notice that antisocial PD is essentially zero at baseline, and is dramatically sensitive to bad parenting. Contrast this with avoidant PD, which, while also sensitive to the parenting, starts out higher at baseline. In other words, you may be born shy, but not antisocial.

Looking at specific types of bad parenting:

What you'll see in the top figure is that being an aversive parent is a great way of making someone borderline or passive-aggressive, not to mention paranoid. But it doesn't make them antisocial. Hmm.

Meanwhile, having low affection or low nurturing scores increased the risk for antisocial, as well as everything else (but especially avoidant, paranoid, depressive, borderline).

Some covariate caveats: even when parental psychaitric disorders and offspring behavioral problems at age 6 were controlled, bad parenting was still associatd with increased risk of their kids' PD.

Furthermore, the usual association of parental psychiatric disorder leading to child PD could be explained, in fact, 95% due to the bad parenting. Another way of saying this is that 95% of the effect that a parental psychiatric disorder has on causing their kids' personality disorder can be obviated by better parenting. In a similar vein, 35% of the effect of childhood behavioral problems leading to later PD can be similarly reduced by better parenting. In other words, even if you or your kids have a "biological" psychiatric disorder, better parenting skills can darmiatically affect the outcome.

It is not an insignificant fact that only one of the 5 authors was an MD (oddly, he is also a PhD but does not list this in the authorship line.). The nature vs. nurture debate in psychiatry is all but dead.

The longer we delude ourselves that biology controls behavior, and not the other way around, the longer we'll have to live with the same behaviors.

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===== ====== ===== The Last Psychiatrist: Parenting and Personality: MAO-A

Continuing the series:

The authors investigate the interaction between child abuse and MAOA (gene) activity on future antisocial behavior.

FYI: MAOA is a gene on the X chromosome-- so males only have one copy. It makes MAO-A enzyme, which metabolizes serotonin, dopamine, and norepinephrine, so having low MAOA gene activity probably means less MAO-A, and thus more serotonin, norepinephrine, and dopamine. MAO-A is in CNS, liver, and GI tract; MAO-B (metabolizes mostly dopamine and phenethylamines (e.g. amphetamines)) is in CNS and platelets.

Importantly, having been maltreated in childhood predisposed you to becoming antisocial; having the MAO-A deficiency, by itself, did not. This is important: MAO activity has no effect in the absence of child abuse. Having low MAOA activity does not predisose you to violence. The abuse is the primary determinant.

What about the interaction between the environment (abuse) and biology (MAOA)? This interaction is very significant, but how you explain this interaction makes all the difference. Here's the figure:

The easy (and wrong) explanation, the one that jumps out at you, is this: if you were maltreated, having low MAO-A predisposes you to becoming antisocial.
But that's not what the figure shows. What it shows is that having high MAOA mitigated, i.e. lessened, the effect of being abused on future criminality.

What you see is that when MAO-A is high, you are protected against the effects of abuse. When it is low, abuse matters.

It may seem like the distinction between MAO being protective vs. being a risk factor is only semantics, but it isn't. How we define the problem actually generates different problems. "Having low MAOA increases your risk of being antisocial" is a very different social problem than "having high MAOA lessens the effect of child abuse." So if you're a lawyer, don't go concocting a "low MAOA made me do it" defense.
As an aside, it might be helpful if someone could explain how having low MAOA is a risk factor for agression and violence, but taking antidepressants (and MAO inhibitors especially) are supposed to make you less violent?

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===== ====== ===== The Last Psychiatrist: Paris Hilton Loses Inheritance

So says, well, everybody.

Maybe you think I shouldn't be closing out the year with a Paris Hilton story (though I did have one before,) but it's much more important than it appears.

The basics are:

Party princess Paris Hilton is $60 million out of pocket after her billionaire grandfather - appalled by her jail term for drink-driving offences - axed her inheritance.
Grandpa Barron Hilton-- the only Hilton to actually own a stake in the Hilton Hotel chain-- is disgusted with her behavior, so will give 97% of his fortune to charity.

Most people's reactions have been, I'm guessing, the exact same one you had or are having. Digg- the unofficial meter of internet vitriol, pronounced this story 13582 levels of awesomeness. The comments were unanimous: "Finally! Justice! That ugly skank got what she deserves!" (Which, presumably, is even less than the millions she will still get.)

What surprises me about this story is this: is there no one who thinks this story is fake?

Consider, for example, Paris's sister Nicky, notable in her own right for, as an example, not making any sex tapes. Was the Barron revolted by the handbag line she designed? He could have just cut Paris out of the will-- it doesn't make sense that he punishes his entire dynastic line (right?)

The first thing that occurred to me-- tin foil hat man that I am-- was that this was a tax dodge. Start talking about charity now, etc, etc, over time maybe Paris et al get on the board of the charity (with accompanying compensation and benefits packages, etc, etc.) So when he finally dies, the IRS gets nothing, and doesn't come looking either.

It's possible I'm wrong (though I doubt it.) But my idea isn't completely preposterous, it's not beyond rational thought, it at least gives you pause, right? So I ask you: how come no one else thought of it?

The answer is emotion. Hate. And bias, but of a specific type. To illustrate, let me rework the opening of the New York Times story:

Today, Vice President Dick Cheney announced that he will donate 97% of his fortune to charity... that money will be placed in a charitable trust that will eventually benefit the Richard B. Cheney Foundation, raising its total value to about $4.5 billion, the foundation said.

That, no one will believe, i.e. you "know" it's a tax dodge. And you know it because you "know" Cheney (which, of course, you don't) and charity isn't his style, unless the charity supports impaling puppies. Meanwhile, you know even less about Barron Hilton, but assume he must be as disgusted by his granddaughter as you are-- sorry, as disgusted by only what the media and she choose to release to the public, as opposed to family get togethers, dinners, birthdays and graduations-- as you are, without any benefit of knowing her at all-- which, when stated that way, seems, well, less likely?

The point is that we make assumptions based not on available information, but on available emotion. That emotion is, in large part, predetermined by the media reporting of it-- note how explicitly the article is biased: "Party princess is $60 million out of pocket..." And it jives completely with your prejudices, so you accept it: confirmation bias. With this kind of reporting, you can't possibly have the cognitive freedom to consider an alternative explanation (like tax dodge.)   And so you don't.

I hope the pleasure we derive from her probably non-existent reduction in inheritance is worth the reduction in our ability to think freely and independently. Maybe the NSA doesn't need to eavesdrop on our thoughts-- it just has to read the newspapers.

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===== ====== ===== The Last Psychiatrist: Paris Hilton or Mary Winkler? Forensics Gone Awry

I'll take Paris any day.
So Paris goes back to jail after the behind the scenes/cover of darkness/MK-ULTRA deal she made to get out of jail early was met by the public with consternation.
As near as I can tell, a/her private psychiatrist (his blog here-- mine's better, dammit) visited her for two hours in jail, then made a plea to the sheriff that serving her sentence in jail was psychiatrically harmful to her. So they let her out to serve it at home.
The argument here, of course, is that this is rich-white-girl gets special treatment; and the easiest way to do it is to use psychiatry. And people say, "see? This is they type of abuse we can expect if psychiatry is allowed to influence legal matters."
Fair enough. I don't know Hilton's case, whether it was a appropriate or not, I don't know Dr. Sophy; all I can say is, yes, the potential for abuse exists, but perhaps it is balanced out by the cases in which it is helpful to society.

But consider the reverse situation, and read it carefully because then I'm going to punch someone:
SELMER, Tennessee (AP) -- A woman who killed her preacher husband with a shotgun blast to the back as he lay in bed was sentenced Friday to three years in prison, but she may end up serving only 60 days in a mental hospital.
Mary Winkler must serve 210 days of her sentence before she can be released on probation, but she gets credit for the five months she has already spent in jail, Judge Weber McCraw said.
That leaves only two months, and McCraw said up to 60 days of the sentence could be served in a facility where she could receive mental health treatment. That means Winkler may not serve any significant time in prison.

Same gripe: look how people use psychiatry to manipulate the legal system-- "only two months for killing someone?!" and while I agree that's pretty pathetic, what's worrying me is this: who the hell spends five months in jail without getting a trial?
This probably didn't occur to you, and that's why it still happens. If I kill my preacher husband, I have the right to a speedy trial. If I can't get a speedy trial, I get to pay a fee to be released, and then show up in court when the government gets their act together. But what if I don't have bail money? How can the courts justify indefinite incarceration in the absence of a trial?
Enter psychiatry. You get a psychiatrist to evaluate the person and determine that he is not competent to stand trial. They recommend 60 days involuntary commitment/treatment in a psych hospital in order to "restore them to competency." If at the end of 60 days the evaluator comes back, and if he still thinks they're not competent-- they get (re)committed again. Etc.
Trial competency has very specific requirements: understanding how you wish to plea, the possible sentences, working with your lawyer, etc. Being depressed or psychotic, per se, isn't the determinant-- only if it seriously impacts your ability to, say, understand the charges against you.
But in the vast majority of cases I have been involved in, the report really only reflects the presence of a mental illness, not its impact to the case. As if it is de facto proof of incompetency. It's not.
But here's the move: the "psych hospital" they get involuntarily committed to is actually their cell.
Technically, they are supposed to be committed to an inpatient hospital. Many jails have them on the premises. But if the commitment is for 60 days, and the psychiatrist treating them (i.e. not the evaluator) thinks they are cured, then they get sent back into population (their cell). Maybe they continue on medication; maybe they see the psychiatrist weekly for "outpatient" visits.
Or maybe, maybe, the treating psychiatrist doesn't think they need any treatment. So they spend their commitment in exactly the place they started.
Worse, much worse, is how many people I see that I say are competent and still wind up recommitted for two months. Six months. A year. Think I'm kidding? It is impossible to even estimate how many charts I have read that indicate no psychiatric contact-- not medication, not therapy, not psychiatrist-- for the entire duration of their commitment. And why should there be? The treating psychiatrist doesn't see anything to treat.
You're probably thinking about murderers and rapists; but the majority of these cases are theft, assaults, drug possessions. Can anyone explain to me what possible justification exists for locking up a guy charged with possession for eight months, no trial? And I'll pretend the guy is whacked out of his nut psychotic. Ok? Any justification at all?
I'm not saying you can't sentence him to eight months-- cane him, for all I care; I'm saying you can't jail him for eight months without a trial. Is anyone listening to me?
The system is designed with simply one outcome in mind: keep the poor with high recidivism rates and minimal social resources in jail-- a sort of half-way house for the disenfranchised-- until you can't possibly justify it any longer, and then give them a quick trial, accept the guilty plea ("what guilty plea?") and sentence them to time served and probation-- where you can add further controls.
It's debatable whether keeping potential terrorists in Cuba is a good idea. But when the State starts using pyschiatry to manage their population...
I know you think I am exaggerrating.   I'll bet you're not poor.

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===== ====== ===== The Last Psychiatrist: Part 2: Why Can't Kids Walk Alone To School

From part 1, here.

VI.

Narcissists don't feel guilt, only shame. Since we are a generation of narcissists, we can't see other people's perspectives, so we extrapolate: we assume that no one else feels guilt either. (And that's probably accurate.)

If guilt is gone, then there are no internal controls to a person's behavior, only external ones.   Follow along:

You may have even been to a psychiatrist a few times-- god knows millions of other people have-- and you're actually normal... imagine how messed up other people are!

And be honest, look into your heart: you're a pretty twisted person. You saw Halloween in the theatre on a weekday at 10pm. At points, the audience was laughing. You know they're not all serial killers, but... isn't that weird?   Well, you laughed at one point, too, but you have control. How much can you trust them, in certain circumstances...?

And I know you and your wife would never try to get your 16 yo cheerleader/babysitter drunk and seduce her, duh, obviously. But that concept is arousing, right? Nothing to feel guilty about, of course, you're not actually doing it...

Here's the problem. Sometime around KROC Howard Stern, admitting such thoughts went from being acceptable ("as long as you don't do it") to commonplace. So there's no associated guilt with the thought, at all. I'm not judging whether there should be guilt, only observing that there definitely isn't any anymore. Include here masturbation, pornography, etc.

So the issue isn't whether there are pervs who might try to seduce your daughter on a babysitting gig after cheerleading practice; you already assume everyone is thinking it, because if you don't feel any guilt, why would they?   What you're left wondering is to what degree external controls-- shame-- are a strong enough disincentive-- word chosen very carefully-- for the other guy. And the answer you're going to come up with is: if there's a way they can get away with it, not very strong.

Societal narcissism has put us in a bit of a bind.

We don't believe that guilt will will control a person's behavior, because we don't feel any guilt in ourselves.
We are very aware of the gigantic numbers of people that have easy access to us, but they are mostly supporting cast in our movie that we know nothing about because we do not really want to know anything about them, so we assume they're like us-- unable to feel guilt.
if you consider yourself ethically/morally above average-- despite the porn, cheating, self-serving lying, then it is entirely logical to assume most people you see in the street are cannibals.
And the external controls you place on your kids and on strangers as protection end up being reminders that you haven't done an adequate job of preparing your child for life.
This is the result: you hover more, trust less, live with an unrelenting low level anxiety, and masturbate a lot.

VII.

And back in the day-- sorry, back in a time you assume existed based on what little you know of it from watching Mad Men or Family Ties-- you could at least trust that women were more moral and upstanding, they kept the men in check. So the fact that a guy was married was one point in his favor. But nine seconds of any modern TV drama-- Private Practice, Brothers and Sisters, whatever-- let you know that a perfectly normal, mannered, intelligent woman will sleep with a guy they don't even like not just for lust or money or revenge-- but for absolutely no reason at all.   They're not just immoral, which is fun; they're amoral, which is terrifying.

"Are you saying women are amoral?" --- No, I'm saying the message men (and women) constantly get is that women are amoral. You did nod three sentences ago, right? Since you are too much of a narcissist to know what women think-- I don't mean you aren't interested, I mean you are unable-- how would you know if TV is wrong?

What happens to society when the kids are taught not to feel safe with women? Guess we'll find out.

VII.

"Are you talking about me?"-- of course not you, you're different.

IX.

This is a good time to point out that when we were kids, we were allowed to walk alone to school, to ride bikes without helmets, got spankings, took our chances down at the creek.   Now we're adults. Look around at the results. Perhaps walking to school alone wasn't such a good idea after all.

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===== ====== ===== The Last Psychiatrist: Partial Objects
I've started a new site, Partial Objects, which is a short form, high post frequency version of TLP, and I'm going to use TLP for longer posts.

I get so many links from readers that time and alcoholism prevent me from writing up with a full post; and so I'm hoping this is a place where I can put down some basic ideas, offer a perspective, and let people comment with their interpretation.

I'm aiming to do 3-4 posts a day on Partial Objects.

I'm also opening it up to anyone who wants to post, the main requirement is that you try to tell the reader something.   If you're linking an article, don't let that article speak for itself-- tell us something that perhaps we wouldn't have seen on our own. Questions are also welcome-- I get a lot of "what should I do about X?" that are worth repeating for other people. I will always try to respond to them.

I hope people find it worthwhile.

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===== ====== ===== The Last Psychiatrist: Pathological Liars

So you think you might be dating a pathological liar? No, you're not. He's just a big jerk.
The popular stereotype of a pathological liar-- a chronic liar, deceiver, who lies to get out of things, or into things; who tries to con you into something, or control you; who cheats on you and then denies it, makes up stories about where he was-- all this is wrong. It's malingering, but it isn't pathological lying. He's a tool, but he's not psychiatric.
"Pathological lying" is often interchanged with "pseudologia fantastica." (NB: many psychiatrists use pseudologia fantastica interchangably with confabulation-- this is also wrong, as will be described below.) Pathological lying was originally defined as complex lies which are internally consistent, that may drag on for years and-- and this is the key point-- do not have an obvious purpose or gain. They're not trying to con you into or out of anything. They're just making crap up.
The lies are unplanned, spontaneous. Once told, they generally stick (for years)-- but it's fair to say the pathological liar doesn't know what he's going to say until he says it. He is a bullshit artist who makes it up as he goes along, and who then semi-believes his own crap.
And the lies aren't even useful lies. You ask him what he did last Saturday and he tells you he went to the museum; and maybe he says at the museum he saw a guy try to rob the gift shop, but he got caught by two off duty cops wearing blue hats. And later you learn he was really at a movie with his girlfriend and you think, why the hell did this freak make all that up?
That's why it's called pathological.
A pathological liar is like a 4 year old kid, who tells you what happened to him down by the lake. Meanwhile, there's no lake.
The important question here is this: does the pathological liar know he is lying? Or does he believe his stories? Is he lying, or is he delusional?
The answer is: both. Sort of.
He is not delusional, but he hovers in that half-world of the narcissist (oh, there's that tie-in), where the lies are believed until he gets caught, but then-- and this is the move that only a few can pull off-- he acknowledges that the "facts" are lies, but not the essence, the spirit. "Ok, look, I'm not really in the CIA." But in his mind, he knows that if conditions were right-- if something big went down-- he could be exactly like a CIA agent, and that's close enough. If he saw a suicide bomber, he'd be able to movie- kung fu him, grab the Sig Sauer and squeeze off a few rounds. He also knows which wire to clip. How does he know? Because he's in the CIA.

If aliens actually did come and attack us, he knows he would actually be able to fly a spaceship.
Pathological lying is not "confabulation." In both cases, lies are told spontaneously and freely, without clear intent, purpose, or gain-- except that in confabulation, the reason the person lies is to fill in the deficits in his memory; he can't remember what actually happened. Hence confabulation is associated with dementia ("when I was 18 I went to Paris with my unit and I saw... 8 puppies get eaten by Chamberlain and de Gaulle-- hand to God I saw it"), and especially with alcoholic dementia/hallucinosis ("I don't know what happened to me-- six guys jumped me... yeah... six... Canadian guys, I think they were Satanists, no, wait, Stalinists, yeah, that's right, and they could read my mind...")
What about biological correlates? There aren't any, because this isn't a disease, it's a description. Here's an example: an article entitled, "Prefrontal white matter in pathological liars" found massively (20%+) increased prefrontal white matter, and a 40% decrease grey/white matter ratio in pathological liars, as compared to both controls and antisocials. But before you crack an anatomy book to figure out what that means (more prefrontal white matter= more ability to think and reason), you should know that the subjects they labeled "pathological liars" were really people who purposely and frequently lie to get a gain-- in other words, they were big fat evil scumbag liars, but not pathological liars. What this study found was that people who frequently lie develop a better brain for manipulating information, remembering stories, etc-- which is interesting, but not all that surprising.
My take is that pathological lying is a disorder of identity; the person imagines for himself an separate identity, and then fantasizes experiences and events which may be otherwise ordinary and predictable-- he went to the museum-- but in his mind happen only to "that" person. The lies hold the clues to that identity, but they may not be obvious. For example, maybe the part of the lie that's important isn't that he saw a guy rob the gift shop and get arrested, but that he was at the museum by himself-- the point is that he imagines himself a loner, or an artsy type, etc. Or maybe he's sees himself living in a world where crimes happen frequently. And maybe he thinks he's a superhero.
The pathological liar doesn't place much value in experience; it's all in identification. He doesn't need to be in the military to know exactly what it's like, because he's watched enough war movies (e.g. one) or read Tom Clancy. (Aside: that's the huge appeal of Clancy and Crichton-- enough detail to make you think you know the inner workings of the professions they describe.) It's wrong to dismiss the lies as valueless; like Zelig, these people do have an intuitive grasp of the relevant thought process, emotions, affects, and even consequences of the experiences they describe. They're just made up. So when he gets caught in his lie, he secretly blames the other person for not appreciating that whether it's a lie or not is trivial, irrelevant; it still affected him just the same.
------------------
(It would be interesting to study whether (true) pathological liars are able to provide a better "profile" of criminals, heads of state, etc, than professional profilers, and what supplementary factors might improve the accuracy of the profile. ("Here are some videos/documents on Vladimir Putin. Tell us what you think. Then, go out to dinner with this beautiful blonde ex-FSB agent and see if you come up with any further insights.") I suspect also that pathological liars would more predictably pass the new fMRI lie detectors; these detect binary lies ("are you this or are you not this?") but pathological liars hold contradictory truths simultaneously and thus may not register as deceptive. (P.S. I think I know how the test procedure can be altered to pick this up; but I also think I know how these tests can be reliably beaten. If anyone wants to study this, let me know.))

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===== ====== ===== The Last Psychiatrist: Paul Ryan vs. Rage Against The Machine

i got you babe

Here's a prediction: This will be the least attended Presidential election in history. Over 50% of the voting age population will not even bother to find out who won, let alone vote. Unless you have money on it when you wake up the next morning at 6am the first sound you hear will be a clock radio playing the counterculture anthem "...then put your little hand in mine..." and you will want to kill yourself. Or marry Andie McDowell, which is only slightly worse. "She was great in Sex, Lies, And Videotape." No she wasn't. Ativan is not method acting.

Paul Ryan says he likes Rage Against The Machine, which everyone thinks is ironic since Ryan is "the very machine they are raging against." Get it?    You're going to read that statement a lot.

I'm not political at all, not only am I not going to vote in the coming election I'm going to hide in the bushes outside my local polling station in a full Raiders uniform and clothesline the highly dangerous people who are only there to vote for Jesus. But while I don't know much about Paul Ryan and even less about Rage Against The Machine, I do know a media set up when I see one.

Ok, so we know Ryan is an idiot for not knowing he's not supposed to like Rage Against The Machine, but did it occur to anyone to ask how we know Ryan likes them, why we know this utterly useless and meaningless and distractionary and prejudicial piece of miscellany? "It was on Ryan's facebook page." Come on, pants on fire, don't act like you even knew he had a facebook page, next your going to tell me you've read the Constitution "several times." You learned it the same way we all did: someone told you it was in a profile about him in The New York Times, and that someone was the only group to have read that profile: other media.

The structure of political reporting is 100% identical to the structure of celebrity reporting: the double act. Straight man delivers the softball pitch:

Yet even if he is viewed as politically pure by the modern-day standards of his party's base, he is not without contradictions. The nation's first Generation X vice-presidential candidate, he is an avowed proponent of free markets whose family has interests in oil leases. But he counts Rage Against the Machine, which sings about the greed of oil companies and whose Web site praises the anti-corporate Occupy Wall Street movement, among his favorite bands.

and the rest of the media hit the punchline. Over and over and over, five nights a week. "He's the very machine they're raging against!" We get it, Rockbrain. Was funny once.

II.

The real irony of this story is that the clueless one is Rage Against The Machine, not Paul Ryan. This isn't a partisan statement, it is simply a fact.

Ryan's main sin is not paying attention to the lyrics, believing he can listen to music without caring about the band's message.

The thing is, Ryan and the rest of the Gen-X coven were taught not to pay attention to lyrics, not just by the mumblings of Nirvana and the distracting Cleveland accent of Rammstein, but by our chief connection to all pop culture in America: commercials.

The title says "Songs Ruined By Commercials" but imagine those ads playing in a different country: their only connection to the songs is those ads. (1)

You ===== ====== ===== The Last Psychiatrist: Pediatric Bipolar. Yeah. Okay.

Rebecca Riley is the 4 year old who died of psychiatric drug overdose-- she was on 3 of them-- supposedly with a diagnosis of bipolar disorder. If you want the scoop from a psychiatric perspective, you should read this post from the resident blogger (no pun intended) at intueri.

But I'll add two things. Let me be very clear: it is not unlikely a 4 year old has bipolar-- it is absolutely impossible. This is because bipolar disorder is not a specific disease with specific pathology that one can have or not have; it is a description of symptoms that fall together. We decide to call a group of behaviors bipolar disorder-- and meds can help them, for sure-- but this decision is completely dependent on the context of the symptoms. Being four necessarily removes you from the appropriate context, in the same way as having bipolar symptoms during, say, a war, also excludes you from the context. You might still have bipolar, but you can't use those symptoms during the battle as indicative of it.   If I transplant you to Brazil, and you can't read Portugese, does that make you an idiot?
I don't mean that 4 year olds can't have psychiatric symptoms. I'm saying you must be more thorough, more attentive to the environment. As soon as a person-- a kid-- is given a diagnosis, it automatically opens the flood gates for bad practice that is thought to be evidence based. That's what makes the diagnosis so dangerous. Instead of, "should I use Depakote in this kid?" it becomes "It's bipolar, so therefore I can use Depakote."

Secondly, we must all stop saying these drugs are not indicated for kids. That's meaningless. We can debate whether they should be used or not in kids, but you can't say they shouldn't be used because they're not indicated. To quote myself (lo, the narcissism):

Thus, categorizing a medication based on an arbitrary selection of invented indications to pursue—and then restricting its use elsewhere—may not only be bad practice, it may be outright immoral.

I do not make the accusation lightly. Consider the problem of antipsychotics for children. It is an indisputable fact that some kids respond to antipsychotics. They are not indicated in kids. But don’t think for a minute there will be any new antipsychotics indicated for kids. Who, exactly, will pursue the two double blind, placebo controlled studies necessary to get the indication? No drug company would ever assume the massive risk of such a study-- let alone two-- in kids.

And which parents will permit their child in an experimental protocol of a “toxic” antipsychotic? Rich parents? No way. The burden of testing will be undoubtedly born by the poor—and thus will come the social and racial implications of testing on poor minorities. Pharma is loathed by the public and doctors alike, and the market for the drugs in kids is (let’s face it) is effectively already penetrated.   There will not be any new pediatric indications for psych meds. Not in this climate. Think this hurts Pharma? It's the kids that suffer.

It's funny how psychiatry always tries to appeal to a higher authority (FDA, "studies", clinical guidelines, thought leaders, etc) except when it gets in trouble. And then it's always the same refrain: "no one can tell me how to practice medicine."

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===== ====== ===== The Last Psychiatrist: Pedophilia Is Normal, Because Otherwise It's Abnormal

i ain't going out like that

Allen Frances, M.D. is a Duke psychiatrist. If you're not particularly interested in psychiatric politics, then the only thing you need to know about him is that after he dies, psychiatry goes full Foucault.

Hebephilia-- the sexual attraction to post-pubescent children, is currently being proposed for inclusion into the DSM-V as a disorder. Should it be considered a mental disorder? (This is different than asking if it should be a crime.)

Allen Frances writes that hebephilia shouldn't be in the DSM because hebephilia is normal.

The basic issue is that sexual attraction to pubescent youngsters is not the slightest bit abnormal or unusual. Until recently, the age of consent was age 13 years in most parts of the world (including the United States) and it remains 14 in many places. Evolution has programmed humans to lust for pubescent youngsters--our ancestors did not get to live long enough to have the luxury of delaying reproduction. For hundreds of thousands of years, sex followed closely behind puberty. Only recently has society chosen to protect the moratorium of adolescence and to declare as inappropriate and illegal a sexual interest in the pubescent.

However, he still thinks it is a crime:

It is natural and no sign of mental illness to feel sexual attraction to pubescent youngsters. But to act on such impulses is, in our society, a reprehensible crime that deserves severe punishment.

II.

If you're surrounded by carpenters, everything becomes about hammers.

Frances and the debate teams are mostly forensic guys, which means their worry about hebephilia's inclusion in the DSM is that it will be used to involuntarily commit people who have NEVER committed a crime to psychiatric hospitals, forever.   The trick is that if hebephilia is in the DSM, TO THE LAW it earns the status of a scientifically accepted diagnosis even if it isn't.

He's probably right about that.

He's wrong about everything else.

III.

The problem with media is that it tricks you into debating the conclusions while accepting the form of the argument. So you get to ask, "is hebephilia a pathological disorder or is it normal?" so that no one asks the question, why do we now, today, want to have this debate?

Pedophilia and hebephilia have always been considered maybe pathological and maybe not; Psychopathia Sexualis makes clear the distinction of the pedophile who has grown weak of moral character (not psychiatric, but criminal) vs. those whose urge towards children is a "pathological perversion" that to him is "quite natural" and is thus "not a criminal, but an irresponsible insane person." The distinction between criminality and pathology has to this point been decided on a case by case basis: "To examine not merely the deed, but the mental condition of the perpetrator."

So why formalize it now? The answer is there in Frances's article, the mistake that is in his article: "sexual attraction to pubescent youngsters is not the slightest bit abnormal or unusual." Dr. Frances thinks he's being historically expansive, boy oh boy did he walk into that one.

If you look closely at your calendar, right after the year you will see, in tiny font, that interest in pubescent girls may be normal; but interest in pubescent boys is always and seriously whacked.

She's 14. Anyone disagree she's... what? Hot? Once you "normalize" sexual interest in 14 year old girls, you either normalize the interest in boys or you quietly suggest homosexuality in general is slightly pathological. You can only pick one, and the rest of us have to live with the consequences.

If hebephilia-- all of it-- is pathology, however, you avoid having to make that dicey distinction. Phew. America is safe.

I am not here making a case for what is normal or not; I'm pointing out the very specific societal approval-- encouragement-- that allows me to keep drooling as long as I ALSO say out loud, "son of a gun, Ali Lohan's only 14? She looks so much older!" but forbids me from even putting up a picture of a boy and making any comment-- even if I am gay; even if I am a woman. Go ahead and try it. And what does it mean that society permits a 14 year old boy to choose to be a girl who is [her]self attracted to males, but in theory lacks the maturity/intellect/right to seduce a grown man? It means stop asking questions, wiseguy. We have a society to run.

As evidence for this, Ray Blanchard, the Chair of the Paraphilias Workgroup at the DSM, wrote a 2800 word justification for hebephilia's inclusion in the DSM in which the words "boy" and "girl" appear only once:

In the third place, a distinction between pedophilia and hebephilia on the grounds of reproduction makes no sense when applied to homosexual pedophilia and hebephilia, since neither pubescent nor prepubescent boys can become pregnant. Lastly, there is no evidence that the arrival of menarche abruptly demarcates girls' attractiveness to heterosexual pedophiles vs. hebephiles

How can you have a debate about what is normal and what is pathology in sexual desire and never discuss the gender? He pulls it off. The point here is not science; neither is the point involuntary commitment. The point is to limit the scope of the debate to manageable, politically expedient constructs. The point is precisely NOT to answer the question.

In this way, Frances and the DSM workgroup he opposes are actually on the same side, the side of the system: using psychiatry as the battleground for difficult social questions. This is how the system defends against change.

The correct way to understand this debate is simply not to have it in this way-- not to be pro or against the inclusion in the DSM: to declare that you refuse to allow it any authority in any direction, ever.   "Well, it's in the DSM!" The DSM has the scientific and moral authority of the Monster Manual, I'm not fooled by its popularity or its binding, and at least that book has the intellectual rigor to base things on a mix of convention and roll of the dice; and I am most certainly not fooled by the antirigorous arguments of the way above their pay grade academics who truly believe they could run the world the way Plato intended them to. Get thee behind me, Satan.

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===== ====== ===== The Last Psychiatrist: Pedophilia Makes You Stupid

Homeland Security Official Charged in Online Seduction

The system has failed.

Plot synopsis: DHS press secretary is caught in online sting, as he has sexual online chats to what he thinks is a 14yo girl but is really a cop.

Seriously, what's wrong with these people? Do you need a 14yo so badly, at any cost, you're willing to tell them you actually work for Homeland? Is that supposed to turn on 14 year old girls?

You would think the deputy press secretary of Homeland Security would know that he could be easily caught on the internet trying to solicit sex from a minor, or at least that the Department would know what he is doing on their computers. But he doesn't, for two reasons: a) he's stupid; b) in fact, the Department doesn't know what he is doing, because the Department is stupid.

I'll do you one better: no one traffics kiddie porn on IRC if they have half a brain in their head. You want to traffic kiddie porn? Make your connections over online games like WoW, Everquest, or Halo. In the case of the former two, the chat conversation works as well as irc, and in the case of the latter, it's voice traffic. In no case is the transcript or anything else logged. I bet there's more weird crap happening in online games than you'd want to know.

Add to that freenet, which is basicaly encrypted decentralized bittorrent with invite-only peers, and you've got a pretty robust digital underground.

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===== ====== ===== The Last Psychiatrist: Penelope Trunk, Abuser

I am accustoming myself to the idea of regarding every sexual act as a process in which four persons are involved. We shall have a lot to discuss about that

Catchy title, no? I put it there for the stupid people. If you think I support domestic abuse-- if you think my not explicitly writing, ad nauseum, "NO TOLERANCE" or "IT'S NOT THE VICTIM'S FAULT" is evidence that I think that "sometimes the bitch deserves it," then I can tell you without error that 2012 is going to be way too complicated a year for you to endure, and you are seeing a psychiatrist, and it isn't helping. Stop being you. The world does not have to validate your prejudices. Take a minute, you may learn from people you disagree with.

I tried my best to read through the comments on Trunk's blog relating to her domestic abuse post, written by people who don't keep diaries about their own abuse history.    "YOU NEED TO LEAVE!!!!!" Assuming you had a similar experience, how long did it take you to leave that earns you the right to a caps lock?

But the title is deadly correct, DEADLY-- see, I earned the right to a caps lock. Here's why, and I expect almost no one to agree with it but hear it once in your life anyway, maybe you make a left instead of a right or you take two more seconds at the light.

II.
Penelope Trunk is a blogger/entrepreneur who is notorious for being "too much information" honest about her life. She recently posted about (yet another) fight with her husband, and posted the pic you see above.
I'm pretty sure she doesn't want my advice, but in the spirit of putting herself out there, I hope she won't mind my using her story to explain something that may help other people. And if I end up being wrong about her specifically, or if it turns out she made the whole thing up, it won't have any effect on the message.

The adage in psychiatry is you can't make a diagnosis without evaluating someone. That's fine, except that personality disorders aren't diagnoses, they are descriptions of behaviors. So stand down.
Penelope Trunk has a history of sexual abuse by her father. She has a pattern of intense, unstable relationships; a history of self-cutting, bulimia; is emotionally labile and reactive; and her primary defense mechanism is pretty obviously splitting, i.e. things are all good or they are all bad.

Trunk says she has Asperger's, and maybe she does, but what I've described is "borderline personality disorder." BPD is not a description of behavior exactly, it is a description of an adaptive coping strategy. In other words, people persist with BPD because it works.

"Works" has a limited definition for borderline: prevention of abandonment.   Narcissism protects the identity at the expense of everything else, Borderline will do whatever it takes to avoid abandonment, including giving up one's identity. Abandonment isn't loneliness or isolation, a person can run away to the woods for a year if it preserves the connection to the other person, even in a terrible way: "I'm hiding out because he's out there looking for me to kill me."

The currency of borderline is affect. Energy. The analogy is the kid who doesn't get enough attention, so acts out: he would rather have hugs and kisses, but he'll settle for the same amount of affect in any other form of attention, including anger and yelling. Negative affect has long term consequences, duh, but short term no affect is completely intolerable. Observe (start at 25s):

The temptation is to view the baby as upset, but in fact what he is doing is trying anything to get her attention, including screaming. This is why what he is is frustrated, and why it is called acting out.

That plays out into adulthood. Knock down fights and great make up sex is psychologically more fulfilling than a normal, calm, low-affect marriage. Mind numbing jealousy is preferable to being 100% sure of their fidelity, to the point that the brain becomes paranoid to keep things interesting.   "Are you just looking for things to be upset about?" The answer is yes. You think Megan Fox's character in the Rihanna video is ever going to settle down with someone who doesn't wear a tank top to facilitate punching?

Why are borderlines attracted to broken men? To alcoholics? To rageful narcissists? Affect. "I never know what mood he'll be in." The range, the energy means you are connected. No abandonment is conceivable if the guy is beating you. "But he cheats on her as well!" He'll be back. Right?

This is set up in childhood 100% of the time. The kid learns what works, learns what gets him the affect he needs. If the parents are loving all the time not much "work" is necessary.    But if Dad is distant, or interested in chasing skirts (such daughters grow up trying to look like the kind of girl Dad is attracted to), or mom's always drunk, then "work" happens, and the kid starts to try new ways of getting the affect, and unfortunately the easiest way to get sucky parents to give you affect is to enrage them. That works awesomely. The best is when the parent beats you mercilessly, and then does a 180 and apologizes profusely, hugs you, buys you gifts, "oh, baby, I am so sorry I did that, Daddy was just upset..." Nothing in life will ever match up to that, except maybe a boyfriend who does that. If you are doing that to your daughter, for god's sake join an infantry battalion or become a test pilot.
Remember: the goal of this strategy is not happiness, it is avoiding abandonment. Hence a blog.
The thing is, BPD "works" when you are young, there are always people around to tolerate it. Parents, boyfriend/girlfriend, employers, etc-- and being pretty, which Trunk obviously is, helps a lot. This doesn't mean people are necessarily nice to her, or that she's happy; only that "crazy" behavior is more tolerable to other people when you are young.

The problem for her is she's not getting any younger, and like it or not the only one who will put up with a 60 year old borderline is no one. Except maybe the kids, which we will get back to.

III.

Telling Trunk to leave her husband is just plain stupid, and if that was your recommendation you should stop making recommendations, you're stupid. You can't reduce the complexity of a marriage to "he hit you, so you should leave." I know stupid people, I know, domestic violence shouldn't be tolerated, god are you dumb.

If she chooses to leave, fine, but trying to convince her to leave pushes her towards her worst fear: abandonment. She either decides to leave, or she doesn't, it must be 260% her decision or else it feels like it isn't all her decision, which means the split is felt like abandonment even though she "did" it. She'll go insane. You advising her to leave means she can't.
It also betrays a gigantic amount of arrogance. This woman who may possibly be a nut has, at least, raised kids, managed businesses, and even survived moving to Wisconsin. And you're going surprise her with "domestic violence is not okay?" But the truth is you don't actually want her to leave, you just want a forum where you can take credit for telling her to do it.

She wants this relationship. She's not a bad or good person for wanting it, it is what it is.   I can say I have my own opinions about what to do and blah blah blah, but the starting point has to be what she wants, not what you think is best for her; otherwise at best what will happen is she ignores your advice, and at worst is she takes it.
Nothing is to be gained by saying her husband abuses her, which he does. The real story is that she is abusing herself. I'm not judging her, I'm not saying she is bad or that I don't understand it, but she's setting up, well, a pattern of intense, unstable relationships because she needs the intensity and will thus tolerate the unstability. A relationship isn't one sided, or bi-directional, it's a dialectic. They are very much in it together.
If you wanted to help (someone like) her, you have to take the focus away from her, put some objectivity into it. So start with her strengths. What is she good at? Raising her kids, for one thing. She may have doubts about her methods or her attention span, but ultimately she takes it all into account and creates an environment that is best for them. Okay, so a good place to start is: how she runs her life, how she runs her relationship, will be inevitably mirrored by her kids. She probably knows this.
What she may not know, however, is that the mirroring doesn't mean her boys will grow up likely to hit their women, but that it is more likely her boys will grow up falling for women like her. Or picking someone in reaction to her.

part 2 soon

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Pesticides And Fruit

everything tastes better with Coke

I.

This is how it works.

They write a study about a link between pesticides and ADHD. I observe that the link isn't the point; the point is to provide another half inch to the stack of "studies about ADHD" so you never question the diagnosis itself.

But there's an unfortunate result of that debate: because I've gone "the extra step"-- gone meta, if you prefer-- you don't think there are any other steps to go.

So you don't think about the pesticides. Because the focus is now on ADHD-- whether the link is real, or whether it's a different syndrome-- you are lulled into false security if your kid doesn't have ADHD. "Phew, I guess the pesticides don't affect him."

II.

In the comments someone had asked: What about a gene that mediates a link between organophosphates and ADHD? A gene that makes you more sensitive to pesticides? That would explain the heritability of ADHD too, wouldn't it?

The NTE gene exists in two copies. If you're lacking both copies of the NTE gene, you're dead. If you lack one copy, you get a 40% reduction in the NTE enzyme (made by the gene). According to this study, deficiencies of this enzyme make mice more sensitive to organophosphates-- it makes them hyper and distractible.

But it matters what you call things. If this were true, then it is only saying that some people (who have deficiency of the enzyme) are more sensitive to organophosphate toxicity. You could even go so far as to say that those symptoms look exactly like ADHD-- but they're not ADHD, they are still pesticide poisoning. You would actually have to go back and say that some kids were misdiagnosed as having ADHD, but they really had pesticide poisoning.

As a techincal issue, lacking this gene/enzyme wouldn't cause an increase in pesticide metabolites in the urine, i.e. lacking the gene wouldn't cause a greater exposure to pesticides, which is what the Pediatrics study detected.

III.

What should we do? Wash our fruits?

This is a meta-analysis of studies of various produce preparation techniques on levels of pesticides. The R* is the percentage of pesticide left on the fruit, e.g. frying removed 90% of the residue.

Baking made the concentration of pesticides go up because of water loss; but much of the pesticides themselves could also have been burned off. So feel free to bake.

Peeling is the best method. The skins of many fruits contain high concentrations of nutrients, but they're simply not worth pesticide exposure.

Washing does not help. Even though it looks like washing helps, most people don't wash their genitals as well as they washed these fruits: soaking in a bucket of water for 5-20min; using acetic acid or ethanol washes; multiple washes with a lot of water; combinations of all of those. And that still didn't do much. If thunderstorms don't wash away pesticides, why would five seconds under the tap? (one, two, three, four, five.)

IV.

The study followed 23 kids over a year, letting them live their crazy lives. But for two non-consecutive weeks, they substituted organic produce:

There are a million other pesticide studies I could have used to show the difference between organic and ordinary produce, but I chose this one to make a different point: you have been lied to so many times, now you are being lied to by yourself.

There is a nearly 100% likelihood that you are looking at this chart the wrong way. You are probably saying, "hmm, I wonder what it was on days 95-100 that reduced their pesticide exposure?" What you should be asking-- and it is not the same thing at all-- is "hmm, I wonder what was going on in days 1-5, 9-93, 180-278 that exposed these kids to such high levels of pesticides?" Normal is NO pesticides. But you've allowed "common" to be replaced with "acceptable."

So let's look at the results here:

1. on the days they got organics, they had minimal exposure to pesticides-- this means that everything else in their life (outside, inside) did not really contribute to their exposure, it was almost all due to produce.

2. better illustrated by a reworking of the above graph:

there was a seasonal effect-- Winter and Spring had higher OP exposure than fall (and summer.)   What's different in the winter and spring? We don't have American produce to eat, what with their EPA controlled pesticide levels. The supermarkets stock the South American produce where, apparently, they have super bugs that can only be killed by plutonium mist.

V.

There is no easy way to present this data, but trust me: it's worth it.

This study looked at pesticide concentrations in fruit based soft drinks, e.g. made by Coca Cola, across the world. The same product, in different countries, has different pesticide levels. Here's one:

Likelihood Of Winning The World Cup

O= Orange drink, L= lemon drink.

1. Depending on which country you're in, you get more or less pesticide. Take that, you Limey bastards.

2. U.S. not shown? Because there are no fruit juices in our fruit juice soft drinks: all artificial flavoring. Yay chemicals!

3. This is only one pesticide. Toxicity to multiple pesticides is not just additive, but synergistic.

4. The max EU standard is 0.1 ppb. That's zero point one. Take that you Fanta drinking scurvy preventing Limey bastards. Should've stuck to rum.

Vb.

Thus, we can make a graph:

This Is Where You Don't Want To Live

See those small purple bars? They represent the EU max, 0.5ug/L. NB: again, U.S. is low not because we care, but because we don't care.

How do you get that much pesticide into a drink with only 5% juice? See II and III above: they get their lemons and oranges from countries with lax pesticide standards, and they don't peel them.

Vc. How can they get away with that? Answer: using words!

The EU max standards, above, are for drinking water. The max standards for fruit are much, much higher, which means this is ok by fruit standards.

You may not think that a 5% fruit soda by Coca Cola is a fruit, but it is.

someone tell me how to peel this bitch

Vd.

I looked for Coca Cola fruit sodas that were tested in the U.S., and found 3-- each had 3% fruit juice. None of them had any detected farm pesticides-- likely due to the use of American lemons and oranges (thanks, farm subsidies.)

However, they did all have 0.4, 0.5, and 0.7 ug/L of carbendazim, a post-harvest antifungal. Which, as near as I can tell, is banned.

I think it's excitingly excellent that though these drinks contain almost no actual fruit, they contain plenty of the pesticides of actual fruit.

---

http://twitter.com/thelastpsych

---

another possible explanation for the rise of "ADHD"

more on pesticides and food

---

===== ====== ===== The Last Psychiatrist: "Pivotal Role That Psychiatry Has Come To Play"
Phillip Resnick, MD is one of five psychiatry expert witnesses in the country. There are actually many more than five, but only about five get used, repeatedly, for big cases. They are very busy, and always on the go. (I was on a case "against" Resnick, and I didn't even see him.)

They are also the main educators in the field. Which is unfortunate. Not because they're bad, but because they are part of that system they are teaching. All they can tell you is what it's like inside the building. Not whether the building is, in fact, a boat, or a duck, or dream.

In an article called, "Being An Effective Expert Witness," Resnick writes:

In fact, the United States Supreme Court has commented on the "pivotal role that psychiatry has come to play in criminal proceedings."²

The reference is from Ake v. Oklahoma. He doesn't say it, but it sounds like he's saying that even the Supreme Court recognizes that psychiatry has much to say about criminal behavior.   See how it's reference 2? It's early in the article, it's in the introduction-- it represents our foundation, our "knowns," before it delves into new stuff. No one investigates the "knowns" because-- they're known. It tacitly endorses the notion "everyone knows psychiatry has much to say about criminal behavior" and uses the Supreme Court (ipse dixit!) as a reference.

In psychiatry, you should always be most suspicious of the Introduction, and the references cited there:

Last, we inquire into the probable value of the psychiatric assistance sought, and the risk of error in the proceeding if such assistance is not offered. We begin by considering the pivotal role that psychiatry has come to play in criminal proceedings...
The Court (Justice Marshall) then goes on to explain the State's obligation to provide psychiatric expert services to those who can't afford it when it is relevant to "an adequate defense," namely, "defendant's mental condition relevant to his criminal culpability and to the punishment he might suffer." They explain what such an expert would do (gather facts, draw plausible conclusions about mental states, explain it all to the jury, etc), but then:

Psychiatry is not, however, an exact science, and psychiatrists disagree widely and frequently... Perhaps because there often is no single, accurate psychiatric conclusion on legal insanity in a given case, juries remain the primary factfinders on this issue, and they must resolve differences in opinion within the psychiatric profession on the basis of the evidence offered by each party.

So: 1) psychiatrists have a limited expertise in criminal matters-- e.g. specifically insanity; 2) juries still must decide, not just because that's the way we set up the legal system, but also because psychiatry is so inexact. It is totally reasonable for juries to disagree with psychiatrists.

In so saying, we neither approve nor disapprove the widespread reliance on psychiatrists but instead recognize the unfairness of [not offering psychiatric experts to the indigent] in light of the evolving practice [of offering them to everyone else.]

It's also worth mentioning that the sole dissent in this case was Rehnquist, who wanted the obligation to provide psychiatric experts to the indigent limited to an independent psychiatric evaluation-- not an expert witness.

Finally: the obligation of the State to provide psychiatric experts exists only if the defendant's "sanity at the time of the offense" is shown to be at issue. If the defense doesn't or can't contest the defendant's sanity/mental state, then the State isn't obligated to provide experts. And merely saying it isn't enough-- it has to be above a reasonable doubt. In this case, the defense did not do this, but be aware that the issue of sanity has to be raised before experts get involved-- i.e. it has to be apparent to a layman looking at the history.

The evidence of the brutal murders perpetrated on the victims [by Ake in the original case], and of the month-long crime spree following the murders, would not seem to raise any question of sanity unless one were to adopt the dubious doctrine that no one in his right mind would commit a murder.

Looking insane isn't enough. Doing really bad things, like setting out with a coworker, tricking your way into a family's home, tying them (a Reverend and his wife) up and then shooting them, raping the 12 year old daughter (and failing) isn't enough. The problem with forensic psychiatry education is the same as for general psychiatry: little time is spent re-evaluating the principles. I'm not blaming Resnick-- clearly, he knows his business well, and his forensic program is well respected. The problem is systemic to psychiatry, and probably to all social sciences. Psychiatrists are trained on how to do things, not whether they are supposed to be doing them, or whether they have the knowledge and ability to do them. Criminality and psychiatry may drive the same roads sometimes, but they don't use the same car.

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===== ====== ===== The Last Psychiatrist: Plan B Emergency Contraception: Doctors Out of Their League, Again

"In a long overdue concession to science, the Food and Drug Administration could finally, grudgingly, be ready to allow an emergency contraceptive to be sold without a doctor's prescription." (USA Today Opinion 8/2/06)

"Concession to science?" Wow!

I have admittedly almost zero interest in the way Plan B has become a proxy war for anti/pro abortion armies. But when doctors become social policy analysts I take note.

Why are "scientists" saying that this drug should be sold without prescription? Why should oral contraceptives require prescription, but this should not? Or, to reverse it, if this doesn't need a prescription, then what does? How do we decide what needs a script and what doesn't? Expediency? Political advantage?

The argument that this is an important option in the event of a pregnancy scare is premised on the notion that Plan B will be rarely used. This is false. It overlooks a very key point: every unprotected sexual intercourse is a pregnancy scare. And people usually have a lot of sex.

Look at it this way:

Before Plan B: you're a woman, you have sex. You're worried-- not really worried, it's not the "right time of the month," he pulled out, etc, etc, but it's in the back of your mind. But there's nothing you can do, too late now, so you just wait it out.

After Plan B: you're a woman, you have sex, etc, etc, but now exists a safe, non-prescription way to ensure you don't get pregnant. Why wouldn't you take it, just in case? Even if the chances you are pregnant are really small-- Why not? What does it hurt? It's safe, the FDA said so, and even put it over the counter. A little nasuea to guarantee you don't get pregnant?

See? It's a no-brainer.

But what about the next night? And the next? What if you have sex-- 10 times a month? It's not frequent enough to embark on the oral contraceptive-- after all, you don't have that much sex, you can't afford to go to the doctor, you don't have the time, etc-- but you know, Plan B is available in seconds... Why not?

I know men who take Viagra "just in case." (And that requires a prescription.) You think this will be different?

Look, Plan B might actually be safe, even if taken every day. But isn't every-day-Plan B chemically identical to an oral contraceptive-- which requires a prescription? And if it isn't safe taken daily, why wouldn't a prescription be required? I should point out that Plan B actually has three times more hormone in it than an oral contraceptive. Hmm. Is taking three birth control pills a day safe? Anyone?

Again, this isn't about whether Plan B is moral or a social necessity-- something on which doctors are no better equipped than lumberjacks to pass judgment. This is about whether Plan B should need a prescription, based on the drug's safety.

This isn't about women's rights or abortion or anything else. It's about "scientists" picking and choosing what they want to believe; about becoming intoxicated with the power to drive social policy, and manipulating the infrastructure of the discipline to generate a smokescreen of science to support them.

Remember: these are the same people who discovered (read: decided) Vioxx causes heart attacks and Zoloft drives people insane-- years after their release-- but Plan B is so safe it doesn't need a prescription.

If I were a class action lawyer, I'd start clearing my desk...

------------------

Levonorgestrel: WHO recommends 1.5mg as a single dose; "Plan B" is .75mg in two doses (12hrs apart.)

Assume the average OCP has 0.25mg of levonorgestrol. (a levonorgestrol-only OCP, called Microval, has only .03mg).

Addendum 11/24/06: Turns out that Plan B emergency contraception does not reduce pregnancy rates. Big surprise. But the one difference was that those with easy access took it more often. (News article here.) My post about this here.

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===== ====== ===== The Last Psychiatrist: Is Obstetrics Worse Than Psychiatry?

Turns out that Plan B emergency contraception does not reduce pregnancy rates. Big surprise. But the one difference was that those with easy access took it more often. (News article here.) So I stand behind my earlier question: why do oral contraceptives require a prescription, but this doesn't?
Coupled with the fact that 50% of abortions are done by women who have already had one abortion at least, and 18% are on their third or greater, and you have a social policy problem on your hands. While everyone is busy with political nonsense, we are missing an important segment of the population that is simply not taking responsibility for their behavior. Having three or more abortions in the United States has exactly nothing to do with abortion rights or women's health issues or access to contraception.

Oh, but it will be okay, won't it? OB/GYN will lead the charge? Sure. Context is everything: in the same issue of Obstetrics and Gynecology from which the above study came is an editorial by Douglas Laube, MD, President of ACOG. He suggests that OB/GYN has lost its way: med schools are not attentive to "differences in gender biology" (seriously.) And he suggests doing something about it:
I will create a task force to assess whether our specialty should adapt behavioral assessment techniques to evaluate candidates’ suitability as women’s health care providers.
I wonder if "suitability" will include social/political beliefs?
Well, he does quote Isaiah Berlin, who
"set in motion a vast and unparalleled revolution in humanity’s view of itself."
Unparalleled?

"His lectures helped to destroy the traditional notions of objective truth and validity of ethics..."
So, even if true (it's not,) is that supposed to be a good thing?
He's also upset that America doesn't pay its elementary school teachers enough.
Oh, and he closes his editorial with a quote "by the prophet Muhammed." Outstanding.
-------
Addendum: Let me explain what I mean by that last sentence, again, it's context: he's not a Muslim. He is (was) a Lt. Commander in the Naval Reserve. Are you telling me that in all of literature, the only quotation he could find to express his point is that one? Does he have a copy of the Hadith handy?   What would you say if Mubarak (Pres. of Egypt) closed a speech with a quote from Augustine's Confessions? This is obviously a ploy, a pretense, he wants to show he transcends the childishness of politics and religion, he's about humanity.

That's where it all falls apart, that's where it stops being science and starts being dangerous.
I looked through six other articles/addresses by him; he seems to be a rigorous and thoughtful clinician and educator-- but-- and this is the but that is killing medicine and society-- he, like so many other doctors, wants to be a social policy analyst. No, no, for the love of God, no.

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===== ====== ===== The Last Psychiatrist: Platinum vs. Gold
God is telling you something

You wait a couple months, then you gonna see
You'll never find nobody better than me

In the night I hear them talk- the coldest story ever told
somewhere far along this road he lost his soul
To a woman so heartless

That woman is credit, her power is flattery...

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===== ====== ===== The Last Psychiatrist: The Ten Biggest Mistakes Psychiatrists Make

Long but necessary.

1. Talk too much

It’s not a conversation, and it’s not a debate. You are either treating their symptoms with medication, or guiding them to “treat” their own symptoms. Neither requires much talking.

If the psychiatrist says more words than the patient, then the psychiatrist is the patient.

Many psychiatrists talk because they feel powerless. The patient is in distress. How can the session be worth the money unless they get some thing? A prescription is good, but what else—what now? So the psychiatrist thinks they need to say something, to appear as though you are giving something to the patient. The worse the situation is, the more the psychiatrist talks. You’re talking to make yourself feel better, to justify your value as a psychiatrist. Don’t do this. It’s not help.

And empathize, don’t sympathize. I cringe whenever I see a psychiatrist on the first visit try to sound genuine while they affect a sad and shocked voice, lean forward, grab a box of tissues, “oh my God, I’m so sorry, that’s terrible!” It’s fake, which makes it annoying, but it’s patronizing, which makes it countertherapeutic. A psychiatrist cannot sympathize—did the same thing happen to you?. What they need to do is empathize, to understand the feelings, to appreciate them—not to share them. Plus, you don’t know what the situation means to the patient. Maybe they’re secretly happy (and guilty about it), and now that you’ve confirmed that it’s “terrible,” they’ll never admit to you or themselves they’re happy about it. Simply saying, “I’m sorry. Can you tell me more about…” is all that’s necessary.

And enough with the tissues. If you stalled the interview to go get them a box of tissues, you have failed, you changed the energy of a key moment. And you did this—let’s be honest—not because they needed tissues, but because it took some pressure off the moment and allowed you to give them something. Leave tissues by the patient chair from the beginning, and focus on what you’re doing.

I had a great mentor who taught me to begin the first session with the words, “Where would you like to begin?” And then to shut up. Great advice.

2. Take too much history

This is going to be controversial. I can hear academics seizing.

I know psychiatrists are taught that careful, meticulous history taking is the cornerstone of good care. Well, it’s not.

Every session should be about the patient, not about you.   You’re supposed to help them, not understand them. The two may go together, but they might not.    It is possible for you to help without understanding, but it is not acceptable for you to understand without helping. You’re not CSI, you’re not Batman, you’re not trying to solve a mystery or make some aha! discovery. They’re telling you what’s wrong. Just listen. Taking a detailed history may seem like a good idea, but many times it is masturbation, it contributes nothing to the patient’s well being, it only makes us feel thorough. As in: well, I can’t do much for him, but I got a really good history. Remember, it’s not about you, it’s about them. It may seem as if a strong family history of bipolar disorder is important information, but it isn’t. I know, bipolar runs in families and blah blah blah. You couldn’t tell they were bipolar before you learned their family history? And how do you know the family’s diagnosis was correct, so that you can rely on it to make your diagnosis?

I’m not saying don’t get the information. I am saying devoting the first one or two sessions exclusively to this gains the patient nothing. Everything from the moment they walk through the door should be about their service. Forget about the notes, especially outpatient notes. Worry about the patient, the notes should come second.

Are you proud of your notes because they contain so much detailed patient information? You need to think about this. Did you break eye contact to write, “sad over husband’s loss?” Then you missed the moment. Just listen—write your notes after the session. And if I see one more psychiatrist with a note pad playing stenographer I am going to punch him in the neck.

3. Ignore smoking cessation

or at least make it a secondary outcome. Also applies to soda/juice/calorie reduction.
This may seem trivial. It’s not—after the treatment of the initial presenting acute symptoms and treating drug and alcohol abuse, this is more important than almost anything in psychiatry. The logic is as follows:

1. Smoking is obviously and severely detrimental to one’s health, arguably more damaging than hypertension and depression combined. Its effect on life expectancy rivals, well, arsenic.

2. It is an addiction, so it is psychiatry’s business.

3. It is highly comorbid with psychiatric disorders, and may be a relative symptom of them. (For example: half of all people who commit suicide smoke.)

4. Smoking itself has a significant impact on other medications (e.g. did you know it reduces Haldol by half?)

5. What the hell else are you doing with the session?   Especially in the “maintenance” phase of psychiatric treatment (where symptoms are relatively controlled, etc).

All of this applies equally to soda consumption or even diet in general. Drinking 2 liters of soda a day may not seem like a psychiatric issue, but most of the medications used have the propensity to increase appetite, and excess eating, smoking, soda drinking are hardly psychologically meaningless behaviors. If your psychiatrist asks you to keep a mood chart or teaches you about “serotonin dysfunction,” but doesn’t tell you to quit smoking, run. He has missed the forest for the trees.

4. Blame lawyers/insurance companies/Big Pharma

In order to understand why this is such a popular mistake among psychiatrists (all doctors, actually) it’s useful to identify when psychiatrists do this. There are two specific times. The first is when psychiatrists seek to justify doing, or not doing, some clinical maneuver, as in, “I can’t discharge him from the emergency room, even though I don’t really believe he is suicidal, I think he is lying simply to get hospitalized-- but I don’t want to get sued.” The second time is when psychiatrists seek to explain a reduction in income, as in, “The insurance company only pays so much for a visit, so now I do only med checks.”

What is striking about these justifications is that they almost never relate to the specific problem at hand, they are scapegoats for some general anger about the difficulty of practice. For example, in the example of the malingering emergency room patient, discharging him has no increased risk of legal liability because if the patient is, in fact, malingering, then he will not kill himself. The operational issue here is not one of increased legal liability, but whether a physician can detect malingering. This has nothing to do with lawyers.

In the second example, while it is certainly true that the insurance company has set reimbursement rates, psychiatrists have not explored their responsibility in this. They have not, in any scientific, economic, and most importantly policy way, justified the necessity for a different (read: higher) reimbursement scheme. Consider psychiatrists’ attitudes towards psychologists acquiring prescribing privileges. It seems obvious that psychologists shouldn’t prescribe medications, but why not, exactly? To say that psychiatrists are trained in medicine and better understand drug-drug interactions, dosing, and toxicities presupposes that the average psychiatrist actually does know about drug-drug interactions, dosing and toxicities. Really? What’s the interaction between Prozac and hydralazine? Don’t know? Then why should psychologists know? And if you can look it up, so can they, etc, etc. Also, using this reasoning could backfire, as it can justify an insurance company refusing to pay for a psychiatric med check since the service could be performed by a primary care doctor (who will also handle everything else for the same low price.) Again, it is easy to complain, but it is on psychiatrists to explain, rationally, why it should not be.

Consider the common complaint that each insurance company has its own formulary, requiring doctors to prescribe alternatives, generics, or submit prior authorization requests. This is taken as bureaucratic interference of patient care. However, in the majority of the cases these restrictions are economically and clinically valid. No logic, let alone evidence, exists for prescribing two antipsychotics simultaneously. So why should the insurance allow it? Similarly, an insurance company should be allowed to approve drugs based on cost, because unless one can show that, for example, two SSRIs do not have the same general efficacy or tolerability across a population, than an insurance company cannot be reasonably obligated to provide both, especially if it can contract to receive one of the SSRIs at a cheaper cost. To be clear: it may, in fact, be true that (for example) two antipsychotics are better than one. But the burden of responsibility is on psychiatrists to show that this (or any clinical) maneuver is necessary, and not on the insurance companies to simply trust that doctors know best, because they have shown repeatedly that they do not.

Blaming lawyers has almost become a sport. It is certainly true that uncapped awards for damages hurts everyone (except lawyers.) However, lawyers are good at picking malpractice cases, not at inventing them. Consider informed consent: if one prescribes valproate for maintenance, one must not only discuss the side effects, but also the alternatives to treatment-- especially when the alternatives to Depakote (a drug which has neither approval for maintenance nor rigorous data backing it) do have such approval and data (consider lithium, Zyprexa, Lamictal, etc.) To prescribe Depakote because it is at the top of an algorithm or in the “guidelines”, or because “that is my practice” and not because of a reasoned analysis of the individual merits of the case, is at minimum not thoughtful practice. A similar example is psychiatry’s current obsession with antipsychotic induced diabetes. Assume that Geodon does indeed have a much lower risk of diabetes than Zyprexa; is a psychiatrist any less liable if the diabetes is induced by Geodon and not Zyprexa? No. You don’t get sued for using Zyprexa. You get sued for causing diabetes and never picking it up.

To state explicitly what seems the most obvious point of all: if a medication causes a side effect, and you catch it, there’s no lawsuit, because there’s no damage.

The above examples come from misunderstanding the available scientific literature, or not knowing it at all. Oddly, if a lawyer does not research the current state of case law and statutes before answering any legal question, it is legal malpractice. But doctors practicing medicine are not required to review current journal articles on any medical condition.

Pharma is the most maligned of all. On the one hand doctors resent the intrusion of the industry on their practice; on the other hand, industry is the primary—often only-- ongoing educational source for doctors, whether they believe this or not. Drug reps, throwaway journals and supplements, “drug dinners” and almost all CMEs (yes, CMEs too, stop lying) are all industry sponsored educational processes which are the de facto continuing education of most psychiatrists.   Oh, right, right-- doctors learn by regularly reading numerous journals carefully and thoroughly. Ok--ask them to name one article in the most recent issue of the American Journal of Psychiatry. Not the results of the study; just the title.

One may want to ask why the FDA feels it necessary to hold pharmaceutical reps to extremely strict standards: they cannot mislead, they cannot speak off label, they must discuss side effects and toxicities, and they cannot use any promotional material that was not reviewed by the FDA. Used car salesmen are not held to any standards, and they sell to idiots. No one needs to tell you the rate of blowouts on a Firestone tire. Why would doctors—the most educated consumer group in existence—need protection from salespeople? Shouldn’t doctors, ultimately, know more about the medications than the sales reps do? Unless…

The sad truth is that the state of psychiatry is the fault of psychiatrists, who have failed to take full responsibility for their own education and practice. To blame anyone else at this stage is remarkably disingenuous.

5. Become social policy analysts

Remember how in May, 2005, the American Psychiatric Association endorsed same sex marriage?   And you applauded the moral fortitude and progressive instinct of this august body? Well, instead of debating whether there should or should not be same-sex marriage, perhaps we should ask what modern psychiatry could possibly contribute to this discussion. The answer is nothing.

You can't get away with pat answers, such as psychiatrists see the psychiatric ramifications of discrimination or being unable to marry. There are psychiatric ramifications of bankruptcy, and war, but no one felt compelled to write a policy statement on it (and thank God.)

And no, there isn't a difference between bankruptcy and gay marriage-- not to psychiatry. That's the point. These are social problems about which modern psychiatry is definitionally ignorant. The APA did not endorse polygamy. What's the difference? If homosexuality is not a psychiatric disorder, than there is no more reason to be more for or against it than there is for any other kind of marriage. The APA is no better suited to answering these questions than, say, the NFL.

What if the NFL came out against antidepressants in children? This is a perfectly valid analogy, because neither the NFL nor psychiatry have special knowledge that make their statements anything more than opinions. What do psychiatrists know about same-sex marriage that the quarterback for the Patriots doesn’t? Don’t laugh—I’m serious. What’s the answer?

Medicine, or the APA, can legitimately express a policy only if the policy was grounded in science or logic. Perhaps the APA cares to release this intriguing scientific data? (While it is at it, perhaps it can also release the data supporting the use of half of the medications currently favored by APA Guidelines?) But this seems pretty much business as usual for the APA. Rather than work on its own serious failings, it involves itself in social policy.

“Modern” (read: pharmacological) psychiatry is obsessed with reinventing itself as a biological and scientific discipline. Well, if it wants to be a science, it better start acting like one.

The FDA effectively killed Vioxx, and not a peep was heard from the APA about the dangers of letting the government regulate their practice. You can say Vioxx has little to do with psychiatry, but it’s still a lot more than gay marriage.

Determining what is true and what is not, through serious and often disconcerting scientific enquiry, is very difficult. It is much easier to involve oneself in matters of opinion and debate, in activism, because it is both immediately rewarding and it is easy. It’s hard to measure things in psychiatry, and when it is possible the results are often disappointing. So it busies itself with matters of conviction because it feels some responsibility to have convictions. It doesn't. It has a responsibility to the truth, and if it doesn't want to invest any energy in that pursuit, it is on them. But don't mask it with whimsy and dilettantism.

I should point out that gays, far from being pleased with the APA’s stand, should actually be horrified. Do you-- does anyone-- want social policy suggested by psychiatrists? Think long and hard.

Imagine the outrage if the APA had come out against gay marriage, or for the war in Iraq. There would be battalions of people saying, "well, what the hell do psychiatrists know about war in Iraq? Who the hell do they think they are telling gays not to get married?" There is no protection in being confident of the rightness of your current position, as history is loaded with examples of how terribly bad doctors are at determining what is right and what is wrong. Not long ago homosexuality was considered a disease. See? The Tuskegee experiments were endorsed by the AMA, and the AMA gave its endorsement, after ethics concerns were raised by Peter Buxtun. Remember that? How about the speech to the1941 APA meeting, and the 1942 issue of the American Journal of Psychiatry in which euthanizing the “feebleminded” (IQ<65) sounded like a good idea?

Psychiatry would do well to remember Wittgenstein TLP 7: Whereof one cannot speak, thereof one must be silent.

6. Don’t refer to therapy.

Psychopharmacology without therapy is treating an infection with Tylenol.

Medications do not cure a psychiatric disease; we’re not even sure what the disease actually is.   What they can do is reduce symptoms, give you strength—so that you can learn new behaviors. That’s the point of medications. Treating depression with an antidepressant is not the solution; it’s the preliminary step in allowing you to figure out how to handle depression later on. The adaptation, the adjustment, the physical altering of brain functioning is done by new learning, often this is therapy (though it doesn’t have to be.) I’m not saying therapy is that great, or necessary, either. I’m simply saying that trying to improve a person’s long term status using medications alone without some sort of education and training is a waste of time. It is maybe the most profound disservice of all to tell a patient that their depressive or bipolar symptoms are the result of biology or chemical imbalances and thus absolve them of the responsibility of learning new ways of interpreting and coping with their environment.

7. Don’t think strategically.

Psychiatry is fun, I’m sure, but it doesn’t help anybody when the patient refuses to play.   Psychiatry telling us opiate abuse is a heritable disorder related to polymorphisms in dopamine receptors doesn’t stop your kid from stealing your money to buy smack. See? Sometimes you have to hide your wallet.
What is the goal? What do you have to do to achieve that goal? Sometimes you have to look beyond the DSM.

Do what you have to do. When a person needs treatment but is refusing it, neither the law nor psychiatry can help them. I can’t force someone into treatment. But you can. Take drug abuse: in my experience, the only way to get someone to (albeit reluctantly) accept treatment is a large scale intervention. 10 people, minimum, in a cramped room with the future patient trapped as far form the door as possible, all ten in energetic agreement that the person needs to get help-- now. Not tomorrow morning. Immediately. You’ve already packed his bags.   This isn’t a five minute pep-talk—take the whole day off, you’re going to be there a while. Also, a psychiatrist cannot do this for you, he shouldn’t even be there, because no one ever listens to neutral third parties, much less psychiatrists. (And I'll just say it: you probably don't want a psychiatrist there in case you...have to take things… to the next level...) It has to be ten highly motivated, concerned people. If you are not motivated enough to stage this uncomfortable intervention, I assure you he won’t be motivated to go. This is the kind of thing a psychiatrist should be telling you, not trying to sell you on Suboxone. Nobody likes confrontation or to be confronted. Ten people. Minimum. Sure, you are partly guilting them into treatment, partly coercing. But getting them into treatment in this way is better than not getting them into treatment in a nicer way. Psychiatry is war.

Sometimes people don’t need to know. If a person’s life is changed on medication, it may be okay not to tell them all the side effects. I know, lawyers are standing by (see # (blame lawyers), but again, it’s strategy, and I think reasonable people (i.e. juries) will understand what you were doing. If lithium keeps the person from slitting their own throat, it’s okay to skip the part about how it can hurt your thyroid. It doesn’t exempt the doctor from checking for it, mind you. In these tricky situations, a) you have to be sure this medication is absolutely vital; b) recruit as many people as possible into the therapeutic umbrella. Tell the wife about the side effect; tell family what to watch out for. And monitor. There’s even a technical term for this therapeutic privilege, but I can’t remember what it was.

Save the environment. Here’s an all too common scenario involving no strategic thinking: Your adult child is living at home, no job, sporadic drug use, involved in an abusive relationship, frequent quasi-suicidal acts, etc. You’ve tried everything, nothing has worked. You don’t know what to do. You’re afraid to kick them out because they can’t manage on their own, you’re afraid they’d sink deeper into drugs/depression/etc; but on the other hand you have other kids you have to worry about, a finite supply of money, etc, etc. You’re paralyzed.

Here’s a question you might not have thought about: what happens to the kid when you die? They are suddenly going to be without support, suddenly without money, suddenly without resources. Will they simply manipulate your spouse into getting their needs met? Or worse, go somewhere else? Is that what you want? Plan today, now, for this eventuality. Maybe that means setting up a trust with a finite monthly payout only if they are living on their own and have a paycheck. Or only if they are seeing a therapist once a week. Or give clean urines. “What is this, probation?” Actually, that’s exactly what it is.

You have to save the environment you are in before you can help the other person. That means protecting your wife and other kids, and their physical assets. It means protecting your marriage.   It may seem cold to worry about money when your kid’s on heroin, but I assure you that this is the most important thing you can do if the kid won’t get help. Ripping apart your marriage over this benefits no one, absolutely no one. So yes, it may mean kicking them out of the house, cutting them off. It also means doing an intervention. It means holding your breath that that phone is going to ring in the middle of the night and it’s going to be the police. But letting them eat, sleep, and watch TV in your house while their chaos continues does not lessen the risk of receiving that phone call.

It’s called enabling. Don’t do it. And a psychiatrist should be telling you this, not trying to give you Celexa to help you cope with it.

8. Polypharmacy

Polypharmacy isn't just common-- it's the codified standard. When two psychiatrists discuss a patient, inevitably one of them will say these four words: “You should consider adding…”

The paradigm is that if you fail a medication, you must be so sick that you need a second medication.

It's a useful paradigm; and by useful, of course, I mean wrong. Here's an alternative paradigm: maybe if the medication didn't work, you should try a different one?

Polypharmacy would be ok if there was at least some data justifying it. But there isn't. I know, controversial. Look it up.

Consider antipsychotics: if anyone can provide the logic-- not data, simply the logic-- for using two simultaneously, I'd love to hear it. Antipsychotics work by blocking dopamine receptors, of which there are supposedly a finite number. If one antipsychotic blocks most of them, where is the other supposed to go? Why couldn't you simply increase the dose of the first? And if side effects prevent this increase, why wouldn't you just switch to the second medication?

Same with antidepressants: Zoloft and Prozac are SSRIs, they target the exact same molecule, which is again finite in number. If most are blocked by one drug, where does the second go? Why are you offended that Medicaid doesn't let you prescribe two at the same time?

So you say: well, what about mixing two drugs of differing pharmacologies, like Zoloft (serotonin) and Wellbutrin (dopamine/norepinephrine)? At least there is logic to this one, but--surprise- no evidence. It may seem as though Zoloft + Wellbutrin, or Depakote + an antipsychotic, etc is better than one alone, but they're not.    But here’s the point: even if it were true, so what? How do you know it’s necessary? Shouldn't prudence and common sense and fiscal responsibility and the cramp in your writing hand require you to at least try monotherapy a few times? Twice, at least? Because I can't prove two drugs are better than one, but I can prove they are twice as toxic and twice as expensive.

Polypharmacy is bastard child of the theory of maintenance treatment. If it took three medications to get you feeling better, then you need to continue these three medications in order to stay stable. Going off your medications results in disaster.

First of all, no. Secondly, take the example of mania. If you're manic, and it took three medications to bring the mania down, does that mean you need those three for the rest of your life? Because if so, what do you do the next time you get manic? Add a fourth? Don’t you get used to medications? Does tolerance not occur? Upregulation and all that? You see the problem-- maintenance begats polypharmacy. Also, medications have side effects, and so medications are given for the side effects of the other

medications, ad nauseum. At some point (four medications?) the symptoms you are seeing cannot be reliably ascribed to the disorder rather than the medications themselves. The patient is buried. The treatment now becomes getting them off these medications.

Again: it may be true that an individual person needs several medications. But you can't make polypharmacy a generalized treatment standard. It's too expensive and has too many side effects for a theoretical benefit. And what kind of message does it send to the patient?    If you're on four medications, how can you be anything but severely ill, all the time? How can you be responsible for any of your feelings, or for controlling them?

9. Diagnose everything

The layman’s argument is that psychiatry pathologizes everything: “well, anyone would be depressed in those circumstances. How is that an illness? And why can you get SSI for it?”

But the truth is in the nuances. When psychiatrists ask you to keep a mood chart, and you report that on these two days your “depression was worse,” what allows the psychiatrist to know that wasn’t normal sadness? Can a bipolar ever be sad for a month and not be depressed?

If a person beats his girlfriends, kills cats, and gets brought by the police because he set fire to a rival’s car, is it possible that his Axis I diagnosis is—nothing? Ok—how many times have you actually written that down? How many times have you terminated the “treatment,” or refused to uphold an involuntary commitment order, because the case was not psychiatric? I know, the system does not have a good mechanism for doing this. I feel your pain. But every time we give some vague “Not Otherwise Specified” diagnosis or pass them along to the inpatient services, we are creating a social policy disaster. We are confirming to the laymen that we think these behaviors are psychiatric, that they are rightfully our purview, and ensuring that a) we will be held responsible for dealing with them; b) we will be held responsible for the outcome.

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===== ====== ===== The Last Psychiatrist: When Your Patient's Parent Is A Psychiatrist and A Patient and You Just Want To Go To Bed

If you want to test the faith of a psychiatrist in their "science", present them with one of their own.
In my career I have treated a few dozen children/spouses of doctors, and about a dozen of psychiatrists. Treating patients with these connections is difficult, if we are to be honest, for two reasons: 1) a lot of the trickery and hand waving we use on regular patients won't work with them, because they know the game. 2) we feel tremendous pressure to do a good job, because we feel that we are being graded.
The result is we almost always do an inferior job. Notwithstanding the admonition against treating family, the reality is that if they knew what to do, they wouldn't be referring them to you. And the trickery and bs are vital parts of the dance: these say you have really no idea why this works, but you're optimistic, so you are offering a framework to think about how it could work. The framework doesn't have to be "true"-- it has to be internally consistent.
But the countertransference towards the patient and his family is so strong that we do things we should not, think things we should not.
Treatment is even harder when both the patient's psychiatrist-parent/spouse is also a psychiatric patient somewhere. If you want to see an entire department blow an aneurysm simultaneously, say, "I'm getting X as a patient, and X's mom is a psychiatrist-- and a patient in the Bipolar clinic!"
In any other scenario, a mom in the bipolar clinic would suggest that the child had a similar disorder, by virtue of being a first degree relative. But in these cases, psychiatrists read it differently: it means the mom made the kid insane. It was the mom's fault. Not genetics, or biology, or even shared environment: specifically bad parenting. And not bipolar-- personality disorder.
I can make a statement that is completely unqualified, without exception: never, not once, has anyone hearing of this scenario said to me something like, "bipolar in educated families is difficult to treat." In every case, again without exception, every single person who has heard of the situation has said the same exact thing: "Oh my God, she's a borderline, and the mom is even more crazy."
What's interesting about this, to me, is two things. First, how immediate, reflexive, and certain everyone is of this assessment-- given even before they ever see the patient, only hearing that the mother of a patient is a psychiatrist. "Mom's a psychiatrist..." Boom. Case closed. Out the window goes diagnosis, biology, serotonin, kindling, TSH, whatever-- it is immediately predicted to be personality disorder due to an unhealthy relationship between parent and child (or spouses). Overinvolved, underinvolved, abusive, manipulative, whatever.
Medications are inevitably thought of as band-aids-- likely to be changed thousands of times over the lifetime-- or proxies for therapeutic maneuvers ("I will nurture you by giving you extra Klonopin to get you through the holidays, but then I will be a disciplined parent-surrogate and reduce it in January.") A family history of CNS lymphoma is less telling than a Dad who is a psychoanalyst.   The adult child is crazy because the parents made him crazy.
That's the first thing. The second thing is this: they are almost always right.
More in next post.

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===== ====== ===== The Last Psychiatrist: Can A Patient Postpone Their Own Death?
Why I hate.

There is a vague but popular assumption that some people close to death from disease can postpone their death in order to get to a special event. Popular examples would be a cancer victim who makes it to his grandson's birth, etc, etc.

History has examples where we assume as much. Jefferson and Adams were in a coma, both until July 4, 1826, the 50th anniversary of the nation. Then they woke up, looked around, and died. "Did I make it?" You made it. Thanks.

Etc.

The authors of one large study discover it is not true. Reviewing 300k cancer deaths in Ohio from 1989-2000, and looking to see mortality rates two weeks before or after Christmas, Thanksgiving, or the individual's birthday, they found no difference in mortality rates.

First, this study doesn't prove that people can't do it. It doesn't even lend any support to the premise that they don't-- it is simply not a well thought out study.   Perhaps Christmas and Thanksgiving aren't a significant pull? It would not have counted Jefferson or Adams as positives. How do you know they didn't successfully postpone their death by a full year, but fall short by two weeks? Perhaps Jews were not particularly motivated to stay alive to Christmas? Etc.

More broadly, from the standpoint of epistemology, the study was flawed from the beginning. You can't use an association study to deny a relationship, only to suggest that a relationship exists. And, you can only do an association study on things you already know exist, to see what kind of association there is between them, not as evidence that one of the things themselves doesn't exist. "According to a review of Chicago ER records, no relationship was found between lunar cycles and the treatment of alien life forms from 1980-2000, thus we conclude aliens do not exist." You are looking to prove something doesn't exist by noting its absence in a few not particularly useful places.

Which brings us to the second point: why do it? There is no information to be gained from this study. Worse, its publication confuses people who think that information was discovered.

It takes away hope. For what? If you knew something for sure, well, then we can debate whether reality is a bitter medicine all must swallow, or not. But this isn't reality, this is... a preliminary investigation designed to drive you crazy. "We have reason to suspect your wife was really good at oral sex with other men prior to meeting you." Now what?

I'm sure these authors are good people, I'm sure they think they have done nothing wrong, but they are not doctors, they have violated the very basis of their profession.

There was no reason for this study at all, as far as studies go. It's a violation of the principles of medicine. It is not science, and it doesn't promote the treatment of patients. It does not contribute to knowledge, it does not contribute to science, and, worst of all, it does not further humanity. Yet here it is, not in some underground fanzine, but in JAMA. Not slipped into JAMA, but past three peer reviewers and an editor into JAMA, not to mention 4 years of "readers." For all their interference in social policy and contamination of medicine in order to further political agendas in the name of "humanity," they think nothing of this.

It is all ego, it is all done for the doctors, it is a study done not to inform medicine but solely so they can say they did a study, "hey, you know the conventional wisdom, well, we just disproved it!" Even though it isn't proof at all, but ha ha and they can gloat over drinks or at the conference and others will point and say, "XX's group at Ohio did a study and they found it wasn't true."

On the one hand, you exaggerate your power, dictate and interfere where you have no authority; on the other hand you pretend you're innocent observers to the freight train of truth, simply taking notes. You violate the trust of humanity and hide behind the pretext of impartiality to the truth, when really you distort truth or invent pretexts for your own prejudices.

When a patient asks me if such is possible, I look them dead in the eyes and I say, "Of course it's possible." I say it because the scope of my field does not have any information that allows me to answer any other way. "Do aliens exist?" Being a doctor doesn't give me any insight into this answer, so you can't use your authority to promote one.

Your job, your obligation, is to serve humanity, if you can do it with science awesome and if there is no science for you then you come up with something else. You don't leave them hanging, you don't leave them hanging. And when all else fails you take out your stethoscope that you don't really know how to use, and you pretend to examine them, you pretend you're involved.

I have no power to revoke your licenses, but if I had the power, if it was up to me, you would all be excommunicated.

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===== ====== ===== The Last Psychiatrist: How To Be Powerful, And Why You Are Not

she has assumed the position

Which guy appears more powerful? They guy with leaning back in a chair, feet up, hands behind his head? Or the guy hunched forward, hands together in his lap?

Which guy do you think feels more powerful?

The study found that assuming the 2 power positions (vs. non-power) for 1 min each had three results:

1. Subjects rated themselves as more powerful (2.84 vs. 1.87 on a 1 to 4 scale)

2. When offered a choice of keeping $2 versus betting it all on dice, 86% of the power group chose to gamble, vs. 60% of the non-power

3a. Their testosterone went up about 15% or down 10% from baseline, respectively:

3b. Power position also significantly lowered cortisol levels by about 15%, while adopting the low-power position had a limited, but upwards effect. Cortisol is usually secreted during acute stress.

All this, from two minutes of a posture change. True for men and women equally.

II.

In fact, the subjects weren't told to sit powerfully, they were told that they needed to sit like that to get a better EKG reading. So power itself was not suggested to the subject. It was merely the act of sitting in that way that made these changes.

This suggests that it was the posture itself that unconsciously(?) altered both self-perception and actual physiology. So, sit up straight.

But it's logical that if that posture unconsciously affects self-perception-- i.e. it wasn't a mechanical effect of having your hands above your head-- then that posture itself serves as the cue. So whether you see it, or position in it, it should have a similar effect.

So not only will sitting like that have an effect on you, but sitting like that will have an effect on whoever is looking at you.

It is a story best told about dating, and in reverse: if a woman sees you hunched over, she'll be biased towards assuming you're not "powerful", and you yourself will feel less powerful.

III.

This isn't anything new, it's long been known that forcing a physical maneuver can alter mood. Forced smiling can make you happier; clenching the fist makes men more aggressive and women feel less in control; method actors key off of physical movements to get their head in gear. And yoga exists.

It should also be obvious that this shouldn't work. How out of touch with our own bodies must we be if we can unconsciously change our mood by accidentally sitting a certain kind of way? And so how much does it therefore suck to be a computer geek hunched over a keyboard 13 hours a day? Time to do some push ups. (I do 40 every hour, between midnight and 2am; take that, guy who hates my physical bravado but is ok with my sexism, raging alcoholism and piracy.)

Some readers will come back with a notion of a mind-body feedback loop, fine, no argument from me; but if these principles are so well known, why don't people do them more often? Why, during a presentation, do some people still hunch over? Why do guys still timidly try to talk to a woman, instead of at least faking confidence and assertiveness? Or at least standing up straight?

IV.

Let's grant that the study is accurate. So if you're a young lad, adopting a powerful position improves your chances of "reproductive success" because she sees you as more powerful, and you feel more powerful, and you have more testosterone angering the blood. Check.

However:

if you consciously adopt a powerful state-- puff up your chest and say, "hey baby, nice stems", and it fails, you're going to look like an idiot. Shame.
Your more natural, timid posture coupled with inevitable rejection is sad but not unexpected. There is less shame.

Similarly, even though an presentation's chances for success are greater if you speak with confidence and stand up straight, doing it that way and failing is a greater blow to your ego.

Notice that the rejection is the same in both cases, but it is felt more severely if you act confidently, posture accordingly. There is more shame.

Thus, increasing your chances of failing is a defense against shame.

V.

That shame is the result of faking it, of putting on an identity that isn't really you (I'm powerful) and having it exposed (rejected.)

The solution is to not fake it. That doesn't mean not try, that means instead of sitting up straight before the presentation, sit up straight all the time. At least train your body to naturally adopt what your mind is too nervous/self-conscious to do.

If this study is at all representative of the truth, it means that eventually you will physically change into the person your body is pretending to be.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Pre-Fed Update
So I was pretty much dead on: GS went to from 190 to 240; GOOG went to Pluto; oil closed at $93 yesterday; and gold went from $720 to $792. As for Dow 15000, wait a month. I was even right about Angelina Jolie; I was wrong about the corn, though.

Tomorrow the Fed will cut .25 because, and this is important, everyone expects them to. I think they would rather not cut, because they see an inflationary picture, high oil, high gold, and strong employment, and no obvious slowdown in consumption. But the Fed game is about managing expectations, because surprise actually hurts the market more than the "wrong" decision. In this case, though, it's the right one. The inflationary picture only applies to rich people; to the others, the picture is recessionary: they're living on credit. Or off their house's value, which turns out is made of gingerbread.

If you want the next investable tip, it's Vegas: put money down on a Republican President. Or, if I am wrong and they don't cut, double down on Clinton.

(Long GOOG, gold, oil; still short Iran, and about to cover on Angelina Jolie.)

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===== ====== ===== The Last Psychiatrist: Presidential Anti-Pharma Rhetoric Heats Up

So once again I’m in the weird position of having to defend something I’m actually against.

The latest is from John Edwards, et al. Here’s the headline: Edwards unveils plan to control drug advertising.
Read that sentence, and decide what you think the intent of the plan is. Is he talking about controlling the colors of the ads?

Most likely, you think it’s the effect the ads have on drug prices.

“The excessive costs of prescription drugs are straining family budgets and contributing to runaway health care costs…”

Let’s temporarily grant that that this statement is true. What is the link between advertising and prescription drug costs? Is he saying that spending on ads increases the price of drugs? That would be wrong, and I have to believe he knows it.

First, Pharma spends about $4b on DTC ads. It has yearly sales of about $200b, so even if every penny spent on ads was instead used to lower the price of the drugs, no one would actually notice. Additionally, prices of branded drugs rise about 6%/year, regardless of how much they spend on ads.

Second, we should probably define “drug prices.” If I roll into a pharmacy with a prescription and choose to pay cash, how much will it be? The answer, as it turns out, depends on the pharmacy. These are retail prices, that pharmacies charge no-insurance cash payers; on average, 15% more than insurance rates. But let’s be honest here: cash payers can’t afford a lot of these medications at any price. If you’re one of the unfortunate working poor who don’t have a prescription plan, you can’t afford the medication at full price, 20% off, even 50% off. The price is irrelevant; what matters is whether you have a prescription plan, or a doctor who can provide samples forever.

So for everyone else, “prices” really means prices to insurance companies, or Medicaid/Medicare, all who negotiate a price that has almost nothing to do with the actual patient demand for a drug. A price which is considerably lower than retail. Medicaid apparently gets a 20% discount, the VA 40%. (1)

So DTC advertising doesn’t affect the price because the consumer isn’t paying it. The price was set in negotiation. Certainly the price Pharma asks from wholesalers and insurers takes into account their costs, including advertising; and more ads (hopefully) means more scripts which means higher profits. But increases in advertising don’t translate directly to higher prices, they reduce the profits. Higher prices are the result of negotiations between parties that are immune to the effects of advertising. That’s the problem.
Third: perhaps what we really mean is that DTC ads raise the overall Medicaid/Medicare expenditures because more scripts are being written that would otherwise not have been written without the DTC ads. Well, if this is what we’re saying, we should just say this; let’s not use factually inaccurate soundbites that play to the hearts of superficial idiots.
But if we are saying this, then the problem isn’t the prices of the drugs, it’s doctors prescribing drugs they shouldn’t be prescribing. The solution isn’t, therefore, to reduce drug prices; in fact, that’s the opposite of what you want, because it makes it even easier for doctors to prescribe what they shouldn’t be prescribing. The actual solution would either be to raise drug costs (bad idea), controlling doctors’ prescribing (bad idea), or giving them a medication budget they have to stay within, but preserving prescribing freedom.

It should bring us pause that even the AMA refused to recommend banning DTC ads. If Edwards plan was specifically about protecting the patients from half-truths or seductive graphics that compel patients to request medications that they don’t need or might compromise their health, then I’m behind him 100%. I already think DTC should be banned. But like all political soundbites, this isn’t about content but about ambiance, creating a feeling that he’s all about cutting costs— that’s he’s more than Hillary. Unfortunately, empty rhetoric like this distracts us from real problems, like Iraq, Iran, wealth divergence, recession, etc.

——

1. As a horrifying diversion into drug pricing, let’s look at Medicaid.

Medicaid, by law, will pay (to a pharmacy who dispenses the drug) a percentage of the average wholesale price, plus a dispensing fee. Both the percentage and the dispensing fee vary from state to state, but it’s on the order of 85% of average wholesale price, and $5 dispensing fee. On average, Medicaid pays about $61 per prescription: $14 goes to the pharmacy, $47 to Pharma.   If anyone can tell me how DTC ads affect that, I’m listening. So pharmacies don’t make a lot on this, and it’s a far cry from the markup the pharmacy can impose on a cash payer. And pharmacies aren’t obligated to participate in Medicaid.

In practice, wholesale price is anything Pharma says it is, including some bizarrely inflated price. But whatever it is, I hope it is clear that it has nothing to do with ads.

And then there are the rebates. I hope you’re sitting down.

In gratitude for this excellent reimbursement, Pharma agrees to rebate Medicaid about 15% or the manufacturer’s price, plus an additional rebate every year for the amount of price increase that exceeds inflation. In 2003, the average rebate was 31%.

There’s another rebate. Many insurances have pharmacy business managers (PBMs) who make preferred drug lists. How does a drug get on that list? It isn’t by being cheap; ask Illinois Medicaid in 2005, when they wouldn’t cover Seroquel, arguably the most demanded but hardly the most expensive. What it takes is, as they say in Big Pharma, “our willingness to play ball.” Another “rebate.”

That money stays in the managed Medicaid’s pocket. The savings aren’t passed on to the patient, either directly or indirectly.   If you want an analogy, it’s the parking authority; revenue from tickets doubles, triples, but the amount they pay to the cities doesn’t change.   The extra “profits” goes back into the authority, to hire more people, pay more salaries. It’s a self-propagating bureaucracy. I should also mention that, consistent with bureaucracies, it can’t even collect those rebates very well.

===== ====== ===== The Last Psychiatrist: Pricing of Placebo Affects Efficacy
An article from JAMA, saying that patients believed $2.50 placebos were more effective than $0.10 ones.

The question isn't why does this happen. The question is, why, in a free market, does the placebo have two different prices?

This is the wine story, redux. In that story, people thought that the more expensive wine tasted better than the cheaper one, even though it was actually the same exact wine. The important part of that story was that this wasn't an error: the brain actually perceived the wine as tastier.

The solution to this apparent human failing is that price itself is a part of taste, not just a marker of taste. A Hermes bag is more enjoyable than a knockoff, no matter how good the knockoff is. Ask anybody who has one.

What the JAMA article tells us is that the placebo effect can be augmented, fine tuned-- but this is the key-- with factors which are themselves not placebos.

The placebo pill itself-- sugar-- presumably has no effect; it is endowed with power by the doctor or researcher that the patient accepts as valid. But in this case, these placebos carry additional information that does not rely on the doctor at all-- price. The patient doesn't have to rely on the doctor's suggestion, he now has an externally valid guide to intuit a drug's effectiveness.

This works only if price is a reflection of value-- be it taste or efficacy. The problem is that, as I've previously written, drug prices are completely disconnected from their relative value, both against other kinds of medications (Nexium vs. tamoxifen) and of drugs within their own class (Zoloft vs. Prozac.)

The experiment in differently priced placebos is at the heart of what's wrong with our misguided obsession with "Big Pharma drives up prices." The public, in essence, cannot possibly fathom that a free market economy would allow, or generate, a pricing scheme that was uncoupled from quality; that allows the same object to carry different prices. Nor that a doctor would not see through such a phenomenon, if it existed.

The public doesn't yet know that drug prices and values are in no way connected, at all. Because it's not a free market.

And so, we erroneously conclude that meds are too expensive. They're not. They are artificially priced. The average person doesn't know that you don't have to use Lipitor, especially at $7 a pill. (BTW: this is why number needed to treat is such an important concept.) They still believe the doctor has made these value distinctions. But doctors have no incentive at all to make them. They don't have to worry about the money.

People believe that healthcare, and especially pharmaceuticals, are too important to leave to the free market. But there are unintended consequences of slapping aside the Invisible Hand. You may not see it slap you back.

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===== ====== ===== The Last Psychiatrist: Probably Not The Best Lesson, But One Of The Few I Know
She's 4, and she's sobbing and chasing her brother, five, around the room. "Stop!" she yells, "stop! I'm trying to tell you something! Stop!"

He's giggling, running away from her, he thinks its fun, a game. Laughing so much he's drooling.

"Stop!!!!" hysterically.

I'm exhausted, exasperated, from another day in middle management hell, where everything is urgent and nothing is important. "What's going on up here? What's wrong with you?"

"He won't stop--!" She's still after him.

"Baby, you can't chase him around. You have to learn about how to handle little boys, you can't chase them, you have to stay in one place and then they'll want to come to you."

And her eyes say ? but she statue-freezes, a temporary hold on tears. She looks straight ahead.

True to destiny, her brother, still giggling, stops, turns, comes bouncing back, stopping within inches of her, staring into her eyes, smiling, waiting to see what's next--

and as she sees him come, a smile like a sunrise breaks through, as she starts to learn about power...

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===== ====== ===== The Last Psychiatrist: Product Review: Panasonic PT AX200U (Hipsters On Food Stamps Part 3)

but how will you afford a steak?

Part 2 here

Three questions, open book:

1. Did Hipster Gerry get his money's worth from the University of Chicago, either $100k in future income or knowledge? No.

2. Did society get their money's worth in sending him, i.e. by permitting/facilitating the diversion of his intellect into whatever it was he majored in? No.

Neither of those questions have the force to change reality. This one does:

3. Did the University of Chicago get their money's worth out of him, was $100k worth the dilution to their brand?   No.

Universities are going to need to differentiate themselves as something more than a processing plant for future consumers of Chinese textiles, local produce, and California pornography. But that time is a long, long way off. What can universities do in the meantime, to keep up their brand in the face of thousands of product recalls every year?

Time for the go team: The New York Times.

II.

The NYT has an article criticizing hipsters. How much would you pay for such an article? (NB: you paid zero for mine.) That's a legit question, not "you get what you pay for." Ten cents? A dollar? Remember that figure, we'll come back to it.

This is how the article begins:

If irony is the ethos of our age -- and it is -- then the hipster is our archetype of ironic living.

If your reservoir for archetypes goes back only one generation, you need your eyeball scanned, you're probably a replicant. Keep that in mind, we'll come back to it, too.

The ironic frame functions as a shield against criticism. The same goes for ironic living. Irony is the most self-defensive mode, as it allows a person to dodge responsibility for his or her choices, aesthetic and otherwise.

So this is true, but that's the secondary purpose of irony, not the primary purpose: in exchange for this self-defense, it puts all of the ironist's energy in the service of the thing it is defending against; that while he affects a distance from "all this", he participates 100% in it. However much the "not corporate" hip coffeehouse needs the barista's extensive roasting knowledge or values the ambiance he creates with his MFA and thoughts about 2666, it is way more than the $7/hr no benefits it is paying him, but they got him, making skinny lattes for an organ donor in a light blue North Face coat while he and his Julliard buddy Garf roll their eyes disdainfully when she asks for two Splendas. "You're saying he's underpaid?" Yeah, but not the point, the point is why does he accept it? It's only because he can roll his eyes about how mainstream she is that he stays, it offers him a perch from which he is better than her, while simultaneously and no less ironically, this woman thinks she is better than him because she's on the correct side of the counter and her husband works on Wall Street. In math terms, the difference between what he is actually worth and the amount he is paid is how much he values feeling superior to MILFs.

Or, if I can be permitted a judicious use of psychoanalytic jargon: it's the rationalization that allows you to blow a guy you can't stand, "I hate him but I'm going to make him cum so hard he'll just want more of me, which will be his punishment." Let that analogy sink in for a moment. From his perspective, not only did he still get blown, he liked it even more. NB: in this analogy, the guy is capitalism and you're not.

III.

Christy Wampole is an assistant professor of French at Princeton University, so right away you should be suspicious of her allegiances, so I figured this was just another NYT hit piece for its overeducated and overpaid demo. But then this happened:

[The hipster] is merely a symptom and the most extreme manifestation of ironic living.

Hold on, something is amiss. There's a gigantic difference between an "archetype" and "merely a symptom", e.g. one is cause and the other is effect, and for a Professor of Confusing Words it's a big mistake to make-- especially when it's been reviewed by the editor at the NYT. It's about as big as missing the primary purpose of irony. Cause, or effect? They are almost opposites, which means she's wants them to be the same, which makes this evidence of a defense. So this article isn't simply "kids today are lazy." There's something else happening:

For many Americans born in the 1980s and 1990s -- members of Generation Y, or Millennials -- particularly middle-class Caucasians, irony is the primary mode with which daily life is dealt. One need only dwell in public space, virtual or concrete, to see how pervasive this phenomenon has become. Advertising, politics, fashion, television: almost every category of contemporary reality exhibits this will to irony.

"Will to irony" may mean she's an idiot, and if this were true I could happily close my computer and buckle down to another night of alcoholic hallucinosis, but she's not an idiot, she's probably smarter than me, which means something far more sinister is going on: conflating the irony of the kids with the irony of the "public space." Who does she think made the public space? 20 somethings? Who is running the advertising agencies? Who is running for politics? How old is every legit fashion designer? Who is responsible for the human rights violations of the ABC Network? She's not decrying the hipster generation, she's describing hers.

IV.

Here is a paragraph so preposterous I was sure this was a McSweeny's gag. But she didn't mean this to be ironic, which is itself ironic, good luck not laughing:

Born in 1977, at the tail end of Generation X, I came of age in the 1990s, a decade that, bracketed neatly by two architectural crumblings -- of the Berlin Wall in 1989 and the Twin Towers in 2001 -- now seems relatively irony-free. The grunge movement was serious in its aesthetics and its attitude, with a combative stance against authority, which the punk movement had also embraced. In my perhaps over-nostalgic memory, feminism reached an unprecedented peak, environmentalist concerns gained widespread attention, questions of race were more openly addressed......

"Relatively irony-free! Architectural crumblings! Socially conscious! Bosnia Herzigova or whatever!" I realize Aspirational 14% wants their beloved 90s to be about something more than just bicuriosity and JDSU, but I was there, it wasn't. Anyone who thinks the grunge movement was "serious" and "combative" and who thinks feminism "reached a peak" also thinks The Hunger Games was a step forward for women and 50 Shades is poorly written "but still hot." Just because you call yourself a progressive or a feminist, doesn't make it true, your progressive passions may end up setting women back five hundred years-- that's right, 500 years. Even 200 years ago Catherine took power away from her husband and became something great, Walpole's is the generation that admires Hillary Clinton as a female role model, not because she became Secretary of State, but because she stayed with her husband so that she could become Secretary of State. Read it again if you didn't get it the first time, it's important. I forbid you from having daughters. Or oxygen. I know, I know, I don't have any real power, but maybe someday a man will give me some.

V.

When someone hates something that to outside observers looks exactly like themselves in every way, you should quickly consult a French book to see if they don't have a word for that phenomenon, and they do, it's called projection.

Before you nod and use it to hate on her, you should understand what projection is. It sounds like you project unwanted feelings onto another person, which is both wrong and impossible. It's not an action, it's a problem of perception. The unwanted feelings don't make sense coming from someone like you, so you conclude they must be coming from the other person.

To use the frequent example of "homophobia": a guy feels gay impulses and can't "handle it" but he doesn't get rid of them by putting them onto someone else, he confuses them as coming from someone else. He smells gayness, "Where is it coming from? Me? Impossible! Jesus washed my feet. Must be that guy." Sorry, wildman, whoever smelt it dealt it. Projection is the most primitive of defenses, circa age 2, and the description should make it clear it is a narcissistic defense: one's perception of the world is inextricably, concretely the result of one's inner states. There is no "objectivity" possible.

The purpose of projection is not to get rid of the feelings, but to explain their presence, to defend the self against a label: "I'm not gay..... even if I have gay sex once in a while." The point isn't to avoid gay sex, the gayness isn't intolerable to them-- e.g. observe the high hat Christians caught in various rest stops across our land-- but even thought they've committed the act, it doesn't affect their identity.

My use of gay as an example is unfortunate because half of you will see "gay" as "bad," but the projected impulse doesn't have to be "bad", merely incongruous to the desired identity that you are trying to solidify. If you doubt this, consider the sullen engineering student at a party, "I'm not like these superficial sorority girls with perfect smiles and condomless sex" who then perceives great happiness in these people.

You could be happy, too, dude, if you weren't so invested in not being happy. If you want a partial understanding of why 19-21 Saudi/Egyptian terrorists could live in America and enjoy our strip clubs but still want to crumble our architecture, there you go.

The article continues with a "nuanced" criticism of irony and the hipster mindset, and then towards the end she tries a reversal, but it's a trick, not because it's not genuine, it is, but precisely because it is genuine:

Obviously, hipsters (male or female) produce a distinct irritation in me, one that until recently I could not explain. They provoke me, I realized, because they are, despite the distance from which I observe them, an amplified version of me.

So true; totally wrong. When people "figure themselves out" and then applaud themselves for their "brutal self-honesty", you can be sure it is further defense. The easiest way for a self-aware person to protect himself is to "figure out" something that is actually correct so that he stops there and doesn't go any further, which is also the problem with most therapies. "I'm learning a lot about myself and my motivations." No you're not. "Figuring yourself out" not only fails, but is the defense itself. Stop doing it.

She thinks she "realizes" hipsters are an amplified version of her, i.e. that she is projecting-- which is in fact/duh correct, but never asks the question, "Why am I projecting? What do I benefit from this madness? How does the system benefit?"

There are so many ways, let's just take one.   Is the result of her work product ironic? Yes. Then it's in the service of the system, while she is able to affect a distance from "all this" she participates 100% in it.

However much the NYT values her PhD, however much they value her intellect and opinions, it's way more than what they paid her, which is nothing. The question is, why didn't she demand to be paid? I'm not saying you have to do everything for money, god knows I write a lot of blog and drink very long rums and neither one have delivered profits commensurate with the labor. If she was promoting something of course I'd understand writing for free, but what can she do after writing for the Times except write for the Times again? See also Princeton, where you will pay them more to get the degree that they will then pay you less to use for them, in no other profession is learning how to do something more valuable than actually doing it. Is that ironic? Then she is able to affect a distance from "all this" while she participates 100% in it. Undoubtedly she's thinking, "well, hell, I got an article in the Times!" as if that has some incalculable value, but that's the trick. It doesn't. It's a scam.

"I'm not a vicious capitalist, I don't always have to get paid for what I do. I like to participate in the public debate." I. I. I. Stop it, look around! This isn't charity, the Times is a billion dollar corporation and Princeton is in actuality a gigantic hedge fund-- why are you giving them your work for free?    "That's the system, I can't change it." Exactly.

No different than the person who doesn't ask for a raise because they're nervous, "should I ask for 5% more?" and they agonize about it for a month, ten months. The point isn't whether you deserve the extra money, the point is whether you deserve it more than the company, because if you don't take the extra money home to your kids, the company takes it to theirs. Note that no one ever frames it this way, it is always about "making a case" or "explaining how you can both benefit." Note also that in most cases the person you'd ask for a raise is a manager, one who has no investment in that money, it doesn't come out of his pocket. Yet he is the biggest obstacle, he will put sugar in your gas tank to stop you from getting that raise. Is that ironic? Or totally the point?

Glengarry Glen Ross is on Netflix, you should watch it a lot. The easy "critique of capitalism" is that "second prize is a set of steak knives" because that's how little it costs to motivate you to work harder for them, and if that doesn't work there's always "third prize is you're fired." But the real wisdom which is not about capitalism but which is about narcissism comes from understanding that first prize isn't a Cadillac Eldorado, you think Alec Baldwin needs a car?   There is no first prize. Real closers don't want the prize, they want to be the best, that's why they will practice practice practice and don't play the lottery. The car is a temptation only for people who do not know their own value, the value of their own work, who won't lift a finger to advance themselves, who are motivated only by threats or by rewards, who would rather have the appearance of success than actual success. "I got an article in the Times!" celebrates the person whose brain is broken. "Alec Baldwin's character is a raging narcissist!" Jesus are you stupid, Alec's name is MacGuffin, that's why he's in Act I and never again yet propels the story forward. It is irrelevant whether Alec Baldwin has metal testicles or pathological grandiosity, what matters is that after years of C minus work, what finally gets those dummies fired up is First Prize or Third Prize, left to themselves they meander in mediocrity while deluding themselves that they are more than what they do. "I was number one in '87!" So was Alf. And the system knows this, which is why it lets Wampole call herself a professor but pays her like a TA----- and she's upset at hipsters. Is that ironic?

She's criticizing-- sorry, critiquing-- hipsters for their defensive posture against society, and for not working, but, look, at least they are not working for free, like a Matrix battery propping up the very system that sucks the life out of them. "Well, it's cool that I got an article in the Times, maybe I'll get to write another one." I know, I know, the temptation of a moment of celebrity was too great to resist, only a fool would pass it up.   Meanwhile Princeton is happy to use her to market their anti-hipster brand to the demo that has the money to send their batteries to Princeton one day. However much Princeton values her article to the NYT, it is way more than they... never mind.

The thing is, if I tie her to a chair and shine the heat lamp on her and ask her whose fault "all this" is, she'll answer the Republicans. Since she's a nuanced thinker she'll probably say George Bush. And when she has to get a job at Rutgers because Princeton won't give her tenure, she'll blame the tax cuts or "an undercurrent of sexism in academia." But she will save and save and save to send her own daughters to college one day, hey, if you send them to Rutgers they'll generously give a 10% employee discount. Sweet!

You gave the system you don't like a spectacular blowjob, and then try to punish it by making it want you more. From the system's perspective, not only did it still get blown, it liked it even more. In this analogy, the system is the system and you're not.

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Provigil vs. Cocaine

In an attempt to see if there is an interaction between cocaine and Provigil, 20mg or 40mg IV cocaine was given pre and post Provigil (400mg or 800mg) for 7 days. There was an interaction, but it turned out to be positive: Provigil reduced systemic cocaine exposure.

A safety study investigated (in 7 people) the interaction between cocaine (30mg IV) and Provigil (modafinil) 200mg or 400mg, or placebo, and found no synergistic effect on vital signs (T, BP, HR) or EKG. Not only did it not augment cocaine euphoria, it blunted it in one person.

In another study, 62 (mostly black) males addicted to cocaine were randomized to placebo, CBT, or Provigil 400mg. Abstinence, the primary outcome, was measured by benzoylecgonine in the urine. Patients on Provigil were abstinent longer, and produced fewer positive urines (i.e. fewer relapses.) Importantly, no one got addicted to Provigil.

Unlike cocaine and Ritalin (methylphenidate) Provigil did not produce "cocaine like discriminitive stimulus" (i.e. didn't feel like cocaine; Ritalin and cocaine do feel like cocaine.)

That's all we know about Provigil vs. cocaine so far, which is pitiful but not inconsequential. Given Provigil's near absence of terrible side effects, I say it's worth a try.

In the interest of completeness (and correctness) I have to correct the major paper, above (the 62 people with the urine tests) . The authors of that paper propose the following potential mechanism:
Its glutamate-enhancing action (Ferraro et al, 1998; 1999) might be clinically advantageous in cocaine dependence because the repeated administration of cocaine depletes extracellular glutamate levels
Except that the Ferraro paper doesn't actually say that. What it says is that it inhibits striatal and globus pallidus GABA, but doesn't directly affect glutamate.   In order for it to have any effect on striatal glutamate, you needed 300mg/kg (i.e. 21,000mg. See you on the other side.) Given that GABA and glutamate are opposites (i.e. glutamate goes up because GABA goes down), it's probably a small point, but not an insignificant one: if it directly increases glutamate, it could antagonize Lamictal or even potentially cause seizures (and it does neither.)
The second Ferraro reference finds essentially the same thing: inhibition of medial preoptic area and posterior hypothalamus GABA, and consequently glutamate increases. And again, all of this occurs at preposterously high doses (100-300mg/kg.)
In interesting side finding of Ferraro's study is that the medial preoptic area and posterior hypothalamus are primarily controlled by tonic GABA inhibition; consequently modafinil's (or any drug's) effect of increasing glutamate in these areas can be blocked by giving a GABA-A antagonist.
So Provigil operates by (probably) by antagonizing GABA, not specifically by enhancing glutamate (neither synthesis of or transport of).
To further complicate this picture, it may be that the effects on GABA and glutamate are both indirect, and really the result of serotonin agonism. In an earlier study by the same guy, the decreases in GABA were partially prevented by a 5HT3 blocker (think Zofran, Remeron). Does Provigil work through serotonin? In a later study, the same guy finds that at 100mg/kg, Provigil does, after all, increase serotonin in the medial preoptic area and posterior hypothalamus.   (At lower doses, 10-100mg/kg, it increases serotonin in the cortex, dorsal raphe and the amygdala.) (And in another study, (yes, by that same guy again,) 3mg/kg Provigil, which in itself has no effect on serotonin, synergistically augmented serotonin increase to fluoxetine and imipramine.)
We already know that Provigil can reduce the sedation that comes from varying drugs, like SSRIs, general anesthesia, haloperidol, and chlorpromazine. It would be interesting to see if Provigil was unable to improve sedation on Remeron, supporting the 5HT3 hypothesis.

Good luck out there.

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===== ====== ===== The Last Psychiatrist: Pseudoseizures vs. Seizures

The title says it all: Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures.
First, the bottom line:
50/52 patients with pseudoseizures closed their eyes during their "seizure," while 152/156 of actual epileptics opened their eyes during their seizures. That's a sensitivity of 96% and a specificity of 98%. That's gold.
Now, the details:
The authors took 234 consecutive "seizure" patients, hooked them up to video EEGs and stopped their medications. There were 938 total ictal events in 221 patients. 52 (23%) had pseudoseizures, and 156 (70%) had eplieptic seizures.   There was a 3:1 female predominance in the pseudoseizures, no difference in epileptics.
In the epileptics, there was rhythmic eye blinking during tonic-clonic activity, and the eyes closed after theseizure was finished.
An interesting corollary to this is when pseudoseizures occur in an actual epileptic: quoting the authors, "the simple question of eye opening or closure can help differentiate between the two types of events. One previous study found that patients with both types of events tended to have their eyes closed during PNES and open during ES.(6)"
Outstanding.

Of course, this is isn't going to mean much to psychiatrists, apparently.
A questionnaire was put to neurologists (N=39) and psychiatrists (N=75) about the utility of video EEG in diagnosing pseudoseizures. 70% of the neurologists, but only 18% of the psychiatrists, thought that video-EEG was accurate "most of the time" in diagnosing pseudoseizures. 12% of the psychiatrists (no neurologists) said it is accurate "almost never." (3% of the psychiatrists gave no clear response. Why doesn't that surprise me?)

So here are some other differentiating symptoms:
In seizure patients, there is a crescendo-decrescendo quality to the spike-wave frequencies on EEG. In pseudoseizure patients, however, the frequency is the same from beginning to end, and it comes on suddenly as if a switch was flicked. The spike-wave on EEG is actually motion artifact, and typically runs around 4 Hz, while epileptics have frequencies that vary between 4-25 Hz.

In a study of 40 pseudoseizure vs. 40 matched normal controls, the pseudoseizure group had more left handers, reduced strength and speed in both dominant and non-dominant hands, and reduction in the dominant hand advantage in strength and speed (i.e. both hands performed equally badly-- the dominant hand wasn't a little better.) Interestingly and importantly, the authors did not think this was due to faking or psychological factors, but felt that it was due to actual neurologic impariment in bilateral pathways: 65% had had a closed head injury, 27% had had physical abuse, and 17% had had a history of substance abuse. 40% had an IQ less than 90!
A study in epileptics vs. pseudoseizure patients trying to determine how long after admission to a video EEG unit it takes for patients to have events (answer: 88% had it on day 1) also found that urinary incontinence, focal neurologic exams, and tongue biting were about the same in both groups. But more epileptics had events less than one minute, and more pseudoseizures lasted > 5 minutes (and very few (13%) lasted less than one minute.)
Slightly different results were found in another study: 11/28 pseudoseizure patients had them on day 1, but 9/28 needed an average of 5 days. 19/28 had an induced pseudoseizure to IV saline challenge within 3-7 minutes. But still-- 3 days should be enough for most patients.
And alexithymia is of no value. It is found more often in epileptics and pseudoseizure patients equally, though still more than expected in the community. A larger, controlled trial had found a similar inability for alexithymia to differentiate: alexithymia was very common in epileptics (76%) and pseudoseizures (90%). Thus, it is likely that alexithymia is a coping strategy, and not an independent trait.
Addendum 11/5/06: I did find an interesting (Greek) study finding an excess of seizures on full moons (34% vs. about 21% for the other phases.)   Importantly (and in contrast to suggestions by other studies) these were not pseudoseizures, because all patients were monitored. The authors speculate either electromagnetic/gravitational effects (hey, it could happen) or an interaction between the intrinsic seizure threshold and the environment (i.e. you can change you rown threshold.)

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===== ====== ===== The Last Psychiatrist: Psychiatry Is Politics

Psychiatry is politics, it is politics in the way that running for office is politics. It is not a science, it is not even close to science, it is much closer to politics.

A doctor makes a diagnosis of a patient and writes it down on the chart. If it were science, then I should be able to evaluate the patient myself and come up with the same diagnosis. If it is a science but not an exact science, I should be able to come up with the same diagnosis most of the time, and the other times where I disagree I should be able to see why the other person thought what he thought.

But if I can guess the diagnosis without actually seeing the patient at all—but by knowing the doctor—then we do not have science, we have politics.

If you are watching the TV news with the sound turned down, and a Republican senator is talking, and the caption reads, “Tax Breaks for the Rich?” you can guess his position.   In fact, the actual issue doesn’t matter—what matters is his party affiliation. Everything follows from there. Not always, certainly, but enough times that you don’t bother to turn the sound back up on the TV.

Psychiatry is the same way. It is very easy to determine who is considered a “great” psychiatrist, or a “thought leader in psychiatry” based on who is making the evaluation, and not on any merits of the psychiatrist himself. Down one hallway Freud is lauded; down the other he is villified; Kay Redfield Jameson is the hero. But their value, of course, is not at all dependent on what they did—it is dependent on who you are. Ronald Reagan was either a god or a devil depending on who you are, not who he was. It doesn’t seem to matter that most people can’t name one specific thing he did in office, what wars and battles he presided over, what he did or did not do to taxes. Ronald Reagan isn’t a person, he is a sign.

It’s even possible for me to guess the medications a patient is taking based solely on who prescribed them, and not on the symptoms of the patient. Importantly, the possible medications vary widely from doctor to doctor; it is wrong to think my predictive accuracy is based on any fundamental logic or science to medication selection that should be true across all psychiatrists. It's just his regular, unthinking, habit. "I like Risperdal." Are you an idiot? Are there internists saying, "I like insulin?"

Let me be clear: I’m not talking about doctors having unique insights into which medication might benefit a certain patient. (“I think Geodon could work really well here.”) I’m talking about each doctor having a set of drugs he prescribes with such regularity that I can guess them.
---

It stems from a lack of appreciation that mental illness is not a genetic disease, or even primarily a biological one, or even, surprisingly, a psychological one. It is a social disruption. On a desert island, no one can tell you are insane.

The key evidence against my position is that biology is so obviously relevant. There is a hereditary component to many mental illnesses; twins raised apart still often have higher concordance rates than non-twins. But this misses the point of the problem entirely. Consider diabetes: it is obviously a biological disease, with a heritable component. Much more biological than any mental disorder, because you can point to the dysfunctional biology in diabetes, but you can’t do that in bipolar disorder. But despite this biology, the environment is so massively important as to often overwhelm this biological component.

We can consider even further the actual relevance of genetics. Things that we assume are simple genetic outcomes are often more complicated than they seem. Eye color is every 7th grader’s primer for Mendelian genetics. But—surprise—there is no gene for eye color. There are in fact three genes for eye color, and the color is determined by the interplay of all three. So while you can guess eye color based on the parents, you are not always right—because each parent is giving three different genes.

It may be, in fact, true, that bipolar disorder is genetic. Perhaps overwhelmingly genetic, let’s say 40%. We go wrong because we consider genetics a “fixed variable”—we think we can only affect the other 60% of the factors. Right? Wrong; genetics is not fixed. Having a gene may be a fixed, but whether you express this gene or not is most certainly under outside control. Consider gender; absolutely genetic, correct? Not much one can do about it? But lizards can alter the sex of the progeny by changing the incubation temperature of the egg. Think about this. Now, is it not probable that the expression of the genes for bipolar have a lot to do with how you are raised? And we already know that environment affects gene expression, so I’m not speculating here.

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===== ====== ===== The Last Psychiatrist: Psychiatry is the pressure valve of society

In case you doubted, here is today's front page of USAToday: Economy's stuck, but business is booming at therapists' offices.

If that was the end of the story-- if people had social troubles and turned to psychiatry for help because of those troubles, it would be a good thing. Get help where you can.

But the larger problem is that in going to psychiatry, their socioeconomic issues get demoted to "factors" and the feelings become pathologized. Psychiatry doesn't explain, it identifies. You're not depressed because you lost your house; you have depression, and one of the triggers is losing your house. See the difference?

You'll say this doesn't happen all the time, maybe not even the majority of the time. But even if it doesn't happen to a specific individual, it still happens to enough people that it bolsters psychiatry's role as the necessary player in managing suffering of any kind.

A 20% increase in therapy visits will be interpreted by psychiatry as a 20% increase in depression and anxiety. It will say depression has a prevalence of X, it will say it is underdiagnosed and undertreated, etc. And it will creep into the social consciousness that these are pre-existing diseases with triggers, not the consequences of external events.

Society needs that illusion, it needs that lie, because it has created unrealistic expectations in people and no way of fulfilling them. Here's what a society looks like under the similar economic conditions, but without psychiatry:

The absence of hope
Today's popular frustrations over flat-lining living standards have been building for years. The recent boom, felt only by the already well-off, has done little to change that discontent. Labor unrest has been growing for months; violent protests erupted... corporate taxes will be raised and gasoline subsidies cut... The move was designed to take the steam out of boiling anti-government sentiment.
The above article, also from USAToday, has a slightly different title: Egypt's economy soars; so does misery.

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===== ====== ===== The Last Psychiatrist: Psychology vs. Psychiatry

I was sent a question from a recent college grad about whether to go into psychology or psychiatry. I don't know which is better; you should decide which you like yourself. But I can help you succeed in either one.

Since I graduated residency, I have never-- never-- had a patient ask me where I went to college, medical school, or residency.   Whether I went to Harvard or Guatemala, no one would know.

It's true that people assume I'm good because I work in an academic institution, so it lends me credibility. And it helps in court, tremendously, to say I work at said academic institution.

But if you are thinking of being a private practice clinician, it matters not a lick where you went to school-- or fellowship (so don't go.)

What matters is how you set up your practice.
Following the logic above-- and you will initially doubt this, but bear with me-- it doesn't matter, financially, whether you go into psychiatry or psychology.   What matters is how you go into the practice of either.
I'll just refer to psychology right now. And I'm going to talk about money only, not personal fulfillment or career advancement or awards-- all that is your business, and there are plenty of resources to help you. I'm trying to tell you about the money side, which no one else seems ever to want to talk about.
The key difference in the need for psychiatrists and psychologists is the duration of follow-up. The shortage for psychiatrists exists for long term follow-up in Medicaid/Medicare patients. The shortage for psychologists is for short term and CBT for private insurance patients.
To get rich in psychology, it is not necessary to have the best paying patients, but rather to have a steady stream of patients, whether they pay well or not. If you have a waiting list, you win.   How to get such a stream?
If I was a good clinical psychologist-- PhD helpful but not necessary, master's is fine-- I would find two or three good psychiatrists and set up a group. Every patient that comes through them has to have at least an initial eval with you, and vise versa.    This guarantees you volume, which is great, and many of the patients will continue on with you. But even those that don't are still a win, because that first session can be billed at a higher rate.
I would find the nearest academic institution with a "residents' clinic." That's a gold mine. There are a lot of private insurance patients there, who need short term therapy. These academic clinics almost never have enough therapists, because the ones that are on staff are not really incentivized to see extra patients; they're on salary. So there is a massive number of patients who could benefit from therapy, but are on a waiting list, etc, etc. It seems unbelievable, so I'll say it again: university clinics need to refer out. If you can get that overflow, if you can get one or two docs there to vouch for you and tell everyone to refer to you, you win. How do you get them to vouch for you? Well, go back to my Steps: you need a specialty. Do you do CBT? Supportive therapy? Grief counseling? You can do everything if you want, but it is vital that you be known for regular therapy AND something specific. You business card should read, "Grief Counseling and General Therapy" or something like that.
That makes you different and better than other therapists, even if you're not. And makes it ok for you to approach a psychiatrist to get referrals. "Hi, I'm a therapist, send me patients" is very different than, "Hi, I specialize in Grief Counseling, short and long term, so if you have any patients..." Again, the unbelievable truth about referrals: the referrer doesn't actually have to be certain you are an expert-- hell, they don't even have to know you are legitimate. If your niche is sufficiently small, they simply won't have any other names available when they get cornered by a patient. And if they have no other such "expert" in their minds, you will get the referrals. And if just one patient reports back to the psychiatrist that you're good, you win.
Try to meet psychiatrists wherever you can, but the best place I know is through drug reps. Go to one of the "drug dinners" and meet the psychiatrists who attend. Find a psychiatrist-parent-- hell, any kind of doctor-- in your kid's school, meet them, let them know you're open for business. Meet the guidance counselor, tell them you specialize in adolescent issues. (Obviously, make sure you actually do specialize in adolescent issues.) Or Family Systems model. Or divorcing parents. Etc.

Remember: it's not "why refer to me?" It's, "who else are they going to refer to?" A doctor who has any sort of emotional connection to you (i.e. met you once) will more likely refer to you than anyone else.
If you want to work the "best paying patients" angle, then you are looking to work with cash only, reasonably affluent patients. Ok-- why would they pick you? Because you went to Harvard? Because you have a PhD.? No. Either a) you in their insurance network so they can get reimbursed; b) they were referred to you. And so we are back to the beginning: you need a niche, an area of expertise. I am sure there are patients who would prefer to go to someone who did "Psychodynamic Therapy and General Psychotherapy" even if they simply needed grief counseling, because they'll assume you're better.

I'll write more about this later.

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===== ====== ===== The Last Psychiatrist: Psychopaths Are Charming?
Reader feedback appreciated.

I recently wrote about an article on the neuroimaging of psychopaths in The New Yorker, and something else just occurred to me.

It struck me that in almost every lay description of a psychopath, the word "charming" is inevitably used. (In The New Yorker piece, it appears four times.) There is an almost mandatory reference to how seductive, or affable, or personable, or-- charming-- the psychopath is, that always follows the initial description of their criminality or evil. Something along the lines of, "if you're not on guard, if you're just talking to them, you can't help but be sucked in." As The New Yorker describes,

The psychopath talks "entertainingly," Cleckley explained, and is "brilliant and charming," but nonetheless "carries disaster lightly in each hand."
What's surprising about this description (to me) is how wrong it is. Quick example: on Google "psychopathy AND charming" gets 80k hits; on Pubmed it gets zero. In fact, to make the broadest generalization possible-- humor me for a minute-- it applies mostly to women. Men, in the presence of a psychopath, are not charmed, they're infuriated. You don't want to hear their crap, you want to stab them in the eye. It's unusual to find a man who is fascinated enough by psychopaths, serial killers, and the like, to record every Discovery Channel special on them; and the few that do are the type you figure to be a wedgie away from going Zodiac at the frat house. But there are plenty of young women are completely fascinated by them, watch all the TV shows, read the articles, etc.

Since I have no data on the male perspective on a psychopath's charm (or lack of it) I'll speak for myself, and I'm curious to know if it resonates with other people: psychopaths are an endless stream of words. They talk, they talk around, they talk around and around the actual point; they don't open up with "I need something from you" but drown you in endless, pointless but seemingly earnest talk about other things that somehow, in their mind, apply to the current problem. In a word, it is all bullshit. You know it's bullshit, but civility, or insecurity, force you to sit there and listen. It wears you down (which is the point), so that after all the "and my brother then..." and "but she told me that..." "He told me it would be okay if..." he finally asks you for "this really big favor" you are more inclined to give in.   When I do an eval for a criminal trial, getting the truth out of one of these guys is painful to the point of euthanasia. They don't even lie directly to you, they overwhelm you with distractions, red herrings, sleight of hand, you ask, "what time did you get to the house?" and for the next twenty minutes, you never hear the words "time" or house" come out of their mouth.

None of that is charming, or engaging, or even slightly interesting to me.

Yet-- and by example here's one woman quoted in the article--

"He had killed his girlfriend because he thought she was cheating on him," she told me. "He was so charming about telling it that I found it hard not to fall into laughing along in surprise, even when he was describing awful thing," [said Carla] Harenski, who is thirty...
Here's an example from Robert Hare himself:

One of my raters described an interview she did with a prisoner: "I sat down and took out my clipboard," she said, "and the first thing this guy told me was what beautiful eyes I had. He managed to work quite a few compliments on my appearance into the interview, so by the time I wrapped things up, I was feeling unusually... well, pretty. I'm a wary person, especially on the job, and can usually spot a phony. When I got back outside, I couldn't believe I'd fallen for a line like that."

I can see the easy explanation: these women are more easily manipulated, especially because the charm carries a sexual connotation. There's a power differential-- some of the fear is processed sexually, etc. Summary: the women don't see what's really in the psychopath.

But that doesn't seem right; these women aren't stupid; they've been around, and even on some level they must know the guy is bad news. So what if these women who are charmed see something in psychopaths everyone else doesn't? Are they detecting something good, or at least attractive, that I for one can't see?

Here's an example: psychopaths don't have empathy, but more specifically they don't understand other people's emotions. As the article points out, they interpret emotions linguistically, not emotionally. They know the word <sadness>, and the other words that explain or go with <sadness>, but they don't feel it. Perhaps emotional inability is made up for by a better linguisitic processing ability, such that they know/intuit better than most what to say to women, while non-psychopaths find themselves acutely aware of their emotions, but are unable to express them (e.g. are shy.)

Maybe women who are charmed by such men see them less as people and more as stories? Do women who find psychopaths charming also read more novels? Do these women have a common interest in certain types of books or movies? Etc.

Maybe I ormen can't sense the "charming" because men are immediately on the defensive because they sense a rival, or alpha male, etc?

This can be flipped around: we know psychopaths are manipulative, but it would be very interesting to find out how easily manipulated they are. Under what circumstances? Is it easier to trick them with money, numbers, logic, pictures? Do they fall for magic, optical illusions? Is it easier for a woman to seduce them, to manipulate them? Are they an easier mark for a con man?

How do you con a con man?

Addendum 12/8/08: a clarification on this post.

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===== ====== ===== The Last Psychiatrist: Psychopathy, Antisocial Personality Disorder, and Narcissism
Updated 12 years later.

I.

A 1996 editorial by Robert Hare, who is the most prominent researcher on psychopathy, even inventing a diagnostic checklist which for complex reasons he named the Hare Psychopathy Checklist.

The article explains the difference between psychopathy and antisocial personality disorder.

He writes that in 1980 with DSM III, psychopathy was relabeled as antisocial personality disorder.   While they still referred to the same individual, it was the approach that was different. This wasn't just a name change, it was a paradigm shift: instead of describing personality characteristics, it focused on behaviors. Not nouns, but gerunds.

Psychopathy: egocentricity, deceit, shallow affect, manipulativeness, selfishness, and lack of empathy, guilt or remorse

Antisocial Personality Disorder: persistent violations of social norms, including lying, stealing, truancy, inconsistent work behavior and traffic arrests

That this happens in 1980 makes sense, coming at a time where "people are not bad, behaviors are."

Interestingly, Hare is mostly concerned that this relabeling will mean psychopathy will be overdiagnosed. His reasoning is that APD is a broader classification-, and few of these are actually psychopaths.   But once the "diagnosis" of APD is made, clinicians and lawyers may overgeneralize and call them psychopaths.

It matters. As Hare points out, psychopathy is considered an aggravating, not mitigating factor in a crime (opposite to, say, bipolar.) Psychopaths are evil and will do it again, so throw the book at them.

That was 1996.

II.
.
Anyone who has read more than one post on this blog knows where I'm going: What Hare had labeled psychopathy sounds a lot like narcissism.

A glance at the above description supports this, but there are three important differences.

Identity:   The narcissist has identity-- but it is one he chose, not one that evolved naturally. That means he thinks of himself as something-- based on a model. He consciously identifies with someone-- Tony Soprano, the guy from Coldplay, Jack Kerouac, or a combination of traits from people, etc.

The psychopath has no model-- he just exists.

Since the narcissist's identity is entirely made up, it requires other people for constant reaffirmation of his identity and of its value. Psychopaths don't need people for this, they need them for material things.

Ability to feel:

Psychopathy is characterized by a lack of feeling and empathy-- a lack. When he kills you, he does not feel remorse, or fear-- after the immediate emotions, he doesn't feel anything. The next day is the same as the previous day.

"Narcissists, whatever their faults, feel deeply, too deeply. That's why they take rejection so hard."

No. Narcissists appear to have emotions, feelings, empathy-- they cry, laugh, feel your pain, etc-- but none of this is real. They don't feel it. It's not linked to anything internal. They're crying at the funeral, for sure, but on the inside they're wondering why it doesn't hurt as much as they think it should. They're proud at their daughter's ballet recital, but not actually proud, inside they're wondering about their promotion, or that jerk at the store, etc. He may feel pride that she's his daughter, but not empathy, nothing about her as a separate person.

Sometimes even they believe the emotion is real. If you've decided you're The Godfather, then those are the emotions you're going to experience or not experience, with the same intensities. Pride matters, lust won't. Etc.

And don't get confused. Narcissists don't pick their identity based on their genetic or preset emotional range; the choosing of the identity comes first. Picking who you are actually changes how you feel, how you think.

A narcissist is a psychopath who has assimialted the emotions of the character he is playing.

Narcissists don't feel guilt-- based on objective right and wrong-- they feel shame-- based on exposure. When they get caught, they're answer is always the same: "wait, that's not really who I am..."

The only thing narcissists truly feel is the pain of narcissistic injury, and rage.

Potential for violence:

The technical distinction is how psychopaths or narcissists internalize these aggressive or libidinal forces. Both feel aggression, but the narcissist takes that aggression and makes it a part of who he is: I am aggressive, I am an aggressor. The psychopath lacks a properly defined ego. He's not an aggressor; aggression is simply an as needed tool, a means to an end.

For the narcissist, violence is a volitional expression of rage, or the response to a narcissistic injury. If he doesn't get the affirmation he needs; if something threatens his identity, then he attacks.

The psychopath is utilitarian: I needed a burger, you had it, so I stabbed you in the throat. Whatever.

As bad as that sounds, here's the narcissist's discourse on the same crime: I needed a burger, you had it, so I stabbed you in the throat. But wait, that's not the whole story, listen, what I did was justified because...

III.

Someone is going to try and correct me, that what I am actually describing is Kernberg's malignant narcissism, and not NPD, or even "run of the mill" narcissism, which are not associated with violence.

And that would be wrong, which is the whole point. There is no difference between the three, it's all the same, what's different is the execution, not the potential.

There is a limitless, catastrophic potential for violence. That it rarely manifests is exclusively due to circumstances, not internal self controls. He's the married man of 20 years who suddenly needs to stab his daughter 10 times because of something that hurt his pride.

It's the guy who goes to happy hour, then is about to get pulled over for a speeding ticket but is afraid of a DUI so he drives off. During the high speed pursuit he accidentally hits a kid on a bike, but instead of stopping decides now he really has to get away or else he's going to jail, so he drives even faster. Then he tries to run on foot and hide in a building, but-- surprise-- there's some woman there, so now he has to take her hostage because she's seen his face...

The psychopath does all those things because at each moment, that's his only option. The narcissist does them because he's "actually a good person, this stuff is just an aberration, if I can just get away I'll be back to being a valuable person again..."

And you may be tempted to blame the alcohol he had at happy hour. And that would be wrong.

Two kinds of violence: a means of protecting the identity from exposure or harm, or the result of rage from the identity being exposed or harmed.

You say: my narcissist never ran from the cops, he never killed his daughter. But that's because your narcissist had at that moment other ways of dealing with the problem.    It's the potential for violence.

All narcissists have this potential, it is intrinsic to the personality structure, which is defined as "me above all things." Sure, usually they figure out non-violent ways to live their life, but that potential is there.

The reason a psychopath kills is because he is bad. The reason a narcissist kills is so that no one finds out he is bad.

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===== ====== ===== The Last Psychiatrist: Radio Host Has Drug Company Ties
No, not Rush Limbaugh.

NYT (11/08) reports:

An influential psychiatrist who was the host of the popular public radio program "The Infinite Mind,"...earned at least $1.3 million from 2000 to 2007 giving marketing lectures for drugmakers, income not mentioned on the program.

The psychiatrist in question is Fredrick Goodwin. As far as contemporary psychiatrists go, he is gigantic. He invented bipolar disorder. That's a joke, of course, by which I mean it isn't.

I.

He has a radio show? Are you listening, NPR? I want a radio show, too. (Disclosure: I get Pharma money. Is that going to be a problem?) If you hire me I'll stop making fun of you.

II.

But [the producer] said that he was unaware of Dr. Goodwin's financial ties to drugmakers and that, after an article in the online magazine Slate this year pointed out that guests on his program had undisclosed affiliations with drugmakers, he called Dr. Goodwin "and asked him point-blank if he was receiving funding from pharmaceutical companies, directly or indirectly, and the answer was, 'No.' "
I'm not sure what to do with this. Is it possible the producer didn't know Goodwin got Pharma money? Who did he think paid for all that research?

Unless he's specifically worried about the lecture money he got; in which case the implication is that that money is magically more biasing then the grant money, or the government grant money. That would be, well, retarded, right?

III.

He said that he had never given marketing lectures for antidepressant medicines like Prozac, so he saw no conflict with a program he hosted in March titled "Prozac Nation: Revisited." which he introduced by saying, "As you will hear today, there is no credible scientific evidence linking antidepressants to violence or to suicide."

That same week, Dr. Goodwin earned around $20,000 from GlaxoSmithKline, which for years suppressed studies showing that its antidepressant, Paxil, increased suicidal behaviors.
I happen to agree with Goodwin that the data on suicide is tremendously weak. (But since I get Pharma money too, I'm biased...) However, he was never pushing antidepressants anyway; he didn't believe in them. Not because of flimsy evidence about suicide risk, but because of (even more flimsy) evidence of antidepressant induced mania (among other things.) For him and his devotees, it was mood stabilizers all the time.

But what's the controversy? He didn't ignore the data, he didn't hide it. If the money biased him he could have just kept quiet, never mentioned it. Instead, he took his views straight to the public; on the radio, for an hour. And, by the way, antidepressants shouldn't be used in the first place...

He wasn't biased because of Pharma money; he was biased because he believed it.

IV.

To illustrate this, imagine if, instead of debating the suicide risk of a drug for an hour on the radio for everyone to hear, he simply dismissed it-- even when he was one of the guys who discovered it:

...risk of suicide death was 2.7 times higher (95% confidence interval [CI], 1.1-6.3; P =.03) during treatment with divalproex than during treatment with lithium.

What would be even more amazing is if no one cared about him dismissing it.

He wrote that in 2003. 2.7 times higher? You would think that someone (i.e. him) would have made it priority #1 to explore that further. Nope. It is never mentioned again. Certainly not on the radio.

And you would have thought that the public, upset about him openly discussing for an hour on public radio the 2x risk with Effexor and Lexapro, would have been even more upset about not ever mentioning a 2.7x risk with Depakote. Also nope. We had to wait 5 years for the FDA to make a federal case about it.

He interpreted the results as lithium preventing suicide; but, as this is science, can you really afford to assume that?

Nobody cares because he didn't get Pharma money for this, so there was no outrage and an assumption that it couldn't have been biased. His career since the 70s has been lithium; no Pharma money there. Yet it was precisely his devotion to his research on lithium, to his career, which made him blind to his own discovery. It wasn't compatible with his worldview.

Maybe the finding is wrong; maybe the suicide increased because these drugs decrease REM sleep. Maybe a million things. 2.7x. Worth a mention?

Money corrupts; but it is always weaker than personal identity. Even though he was getting an extra $185k/yr from Pharma, which I assume is more than he was getting from his actual job as a researcher, he didn't think of himself as a Pharma lecturer, he thought of himself has a researcher on bipolar and mood stabilizers. That's who he is. That's the real bias, the one that counts; the one that makes him unable to see the very digits he types into a Word file.

And since there is no financial bias, we just eat it.

This is the same problem with Himmesltein's analysis of bankruptcies. When your data are screaming for alternative explanation, but you instead focus only on what you want them to say, everyone loses.

V.

That article was 11/08. It's now 7 months later. What has the outrage over Pharma money got us? He still gets paid for Pharma lectures. Psychiatrists still think of him as gigantic. I'm still neck deep in a field that thinks four drugs at a time makes sense. But he doesn't have a radio show. Problem solved?

If he didn't get Pharma money, would he have been able to afford the time to do a radio show?

I don't know how else to say this so that I'm not misinterpreted: if we persist in using money as a shortcut for critical interpretation, we are lost. And if we fail to appreciate insitutional biases-- "well, this is already established, no one seriously thinks otherwise"-- then we have already embraced despotism.

Addendum: Bill Lichtenstein, producer of the above radio show, comments.

----
http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Everything Is A Teachable Moment When You Are A Piece Of Garbage

I was about to pull the covers up, and she looks at me and says, "Daddy, are all doctors daddies and all nurses mommies?"

Here we go, I think.

Maybe you think this is a simple yes or no question, but it's not, everything becomes strategy. How I answer this will affect the rest of her life, how she'll answer her own questions and set goals and limits for herself. This is a scrimmage to teach her position. Am I smart enough as a parent? Am I ready?

I've mentally practiced this moment, and dozens others like it. For some I even have a script. I know how I want her to think, to make decisions for herself free of outside influences. The trick is how to teach her that, how to make it part of the way she thinks, reflexive.

"No, baby" I say, because it's a fact but facts aren't at issue, I'm the Father and I have a responsibility to help her develop. Ok, look, I don't want her to be a nurse but that's not the point here, the point here is to teach her about choosing your identity. "Some doctors are women, and some nurses are men. You can be either."

Yes, if she was a boy I'd have a different answer. But she's not a boy, and the immediate issue today isn't for her to choose between being a doctor or a nurse, but to understand that she gets to choose.

"Is your doctor when you go to the doctor's office a man or a woman?"

"Sometimes it's a boy, and sometimes it's a girl."

"See?" I say. "It can be either one."

"Then how come you're a doctor? Is being a doctor harder or easier?"

"Harder." No sense in political correctness. "It's harder because you have to decide everything. You're in charge, you have to decide how to help people, what to do next." She needs to know that the difference isn't just amount of calories expended, but of responsibility. "And you make more money." I debate saying this, but I think it's important to introduce the real importance of money, and the relative value of things, and jobs. I'm not going to push it here, just introduce that it exists as a factor.

"How much money?"

"Like, a hundred." It doesn't have to mean anything, it just has to convey a feeling.

"Wow, that's a lot."

"It can be."

"And you put that money in your special place?"

Another opportunity. "Yes, you have to save your money, you have to save as much as you can. Sometimes, even if I want to buy something, I have to decide if I should spend the money or save it. So I save it."

"So we can save and go to Disney?"

"Yes, among other things."

"But nurses get less money?"

"Most of the time, yes."

"But if you're a nurse," she recalls, "you don't have to go to work. You can stay home with the kids and wear a bathrobe, right?"

I laugh. "No, no, if you're a nurse you have to go to work, too. Right now mommy is staying home to take care of you guys, she had to stop working for a while, and when you all get older maybe she'll go back to work." And then I add, "it's up to her." Excellent.

"Oh, so nurses have to go to work, too."

"Yes, if they want."

There is a pause here. She's working through it all. I think I've succeeded; if nothing else, I've taught her that the decision is hers to make. Nothing defines her.

"So I could be a doctor."

"Of course, baby." I'm winning, I see that I'm destroying barriers. Finally. This is what it means, after all, to be a good parent; seeing through the words and striking at the core issues, teaching your children not facts and information but wisdom, power.

Until her eyes fill up with tears, and she says, "I want to be a doctor."

"You can do anything you want." Something's wrong.

She's motionless under the covers, she doesn't look at me. She looks like I've spit on her. "I've already decided," she says, as if to euthanasia, "I have to be a doctor."

"Okay, baby, but-- why are you crying?"

"Because if I'm a doctor I have to work every day, except for I have only one day off, and when I come home I have to work on the computer, and I won't get to see any of my children. Unless they get sick."

And there it is. I've failed, again.

I'm teaching, teaching, but do I listen? Do I hear her, do I hear and see what's important to her, what questions she really has, what's really of value in her life? She just wants to play Lightning McQueen vs. Chick Hicks with me outside, meanwhile I'm trying to teach her that the way to truth is through the inside, or some other idiocy. I may as well leave my stupid aphorisms in a Moleskine for her and then go kill myself. What's she need me for?

Words are the enemy, they are always the enemy, they do nothing but mislead, deceive. If you have to say it, you never did it. What have my words done tonight, that my existence and behavior hasn't contradicted every single day? I'm a failed fraud who's beckoning others down the same path.

I wasted 15 minutes trying to con her that she can be anyone she wants to be, completely missing that she is already who she wants to be, the problem is I'm not who she needs me to be. Life, through its henchmen like me, only chip away at that original identity, making it harder to be satisfied and impossible to be happy. I've taught her that stereotypes are wrong, meanwhile she hasn't even learned the stereotypes yet; in fact, I just taught them to her by denying them. Maybe I should wake her in the middle of the night, grab the sides of her head and shriek, "there's no such thing as ghosts! There's no such thing as ghosts! There's no such thing as ghosts...!"

If I was so smart, if I had so much to teach, I wouldn't be so miserable. And this wouldn't have happened.

Being a good parent often means: knowing your limitations, and getting the hell out of the way.

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===== ====== ===== The Last Psychiatrist: Raising Wine Prices Makes Wine Taste Better
Turns out the Associated Press doesn't read journal articles, either.

The story is that two identical wines, priced differently, are perceived to taste better or worse depending on price.

The study took the same wine poured into two glasses, labeled one $5 and the other $90, and (the AP reports,) the subjects thought the $90 wine tasted better.

Which isn't exactly what happened-- I'll get to that later. Before I read the study itself, my first thought was, "why is this surprising?" Let's take this conclusion at face value-- what does it actually mean?   The assumption is that taste shouldn't be affected by something external, like price.

That's wrong: taste isn't objective, any more than being hot is objective. Taste is legitimately affected by price, because that's a variable in the perception of pleasure.

Which is hotter: a hot girl I tell you is 25, or the same hot girl I tell you is 35, but is actually 25? Her hottness clearly has a variable related to age (sorry ladies) that isn't evident in the physical object (it's the same girl.)

This isn't semantics. That the wine tasted better is not deceptive-- it actually tastes better.   It's real, not illusion, in exactly the same way that meeting a guy you think is an arms dealer/nightclub owner makes him taste better (NO JOKES). The point isn't that you were lied to; the point is that information affects "taste"= pleasure.

It's Cypher, eating the steak and drinking the wine, knowing it isn't real, yet it still "tastes" delicious. (Spoiler: he dies.)

This experiment isn't scientific because it does not measure what it claims to measure-- the influence of price on the (not actually) objective parameter "taste." An objective study would have been asking the subjects to identify which wines were the same, and to determine if price differentials affected that ability.

II.

Let's look at the article more closely. Sorry-- let's just actually read it.

Right off the bat: it's not about wine. The premise of the study is in paragraph 1 (in which the word "wine" does not appear):

A basic assumption in economics is that the experienced pleasantness (EP) from consuming a good depends only on its intrinsic properties and on the state of the individual...

In opposition to this view, a sizable number of marketing actions attempt to influence EP by changing properties of commodities, such as prices, that are unrelated to their intrinsic qualities or to the consumer’s state.

The article isn't about taste, but the interaction between a sensory experience and the expectation of that experience; specifically, that Experienced Pleasantness (through the brain region which handles it) is affected by variables that are not contained in the object of pleasure, but have in the past been informative about the potential for pleasure. In this case, price.

These variables are not contained in the object, they come from you and placed are placed on the object.

The authors are clear about what they did (not) find:

Importantly, we did not find evidence for an effect of prices on areas of the primary taste areas such as the insula cortex...

Another way of saying this is that naming something affects your perception of it. The authors cite a study in which labeling the identical odor as either "cheddar cheese" or "body odor" affected the perception of pleasantness. A price is also a name, of sorts, in so far as all names are merely signs which convey a message. ("Tammy" vs. "Tami").

Naming something, labeling something, is power. Not powerful-- power. The price is a label. What people are likely upset about is, "so, marketers could simply tell you lies about it, and you'll think it's better than it is!" and if you said that, you're missing my point: it isn't better than it "is." It isn't anything. It's just a stupid drink.

Or, you may lament, "so advertisers can tell us may actually affect our perception of pleasure by telling us it is better! That's unfair!" Unfair is not the right word. It's surreptitious. But it may actually enhance your pleasure. "But they're taking my money on false pretenses." Yes, that's another issue-- how much you're willing to pay for your "illusion" of pleasure. Have you seen a Julia Roberts movie?

We might all have what the Matrix referred to as "residual self image," and I'm sure it's great, but ultimately you are only what you did (and thought.) You're not a coward until you act like one, and even then there's always tomorrow when you can be something else.

There's a human bias that things have a nature and a value independent of our perception, and this is in some ways accurate; but let me soften my position and simply say that we can strongly alter this simply by naming it. Change perceptions, relationships-- how you interact with it, how you view it.

I hardly need to reiterate that this is precisely what psychiatric diagnoses are about.

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===== ====== ===== The Last Psychiatrist: Ramachandran's Mirror
And I don't like what I see.

For three years I had been seeing her for "Major Depressive Disorder" and been treating her with Effexor and Restoril and thought I was doing a good job of it, too. Proud of myself, you see, that I had reduced her symptoms AND managed to keep the number of pills she was on to well under the psychiatry average of 19. I rule.

Also and by the way, she had an above-elbow amputation from a bus accident ten years ago. She had phantom limb pain, in this case feeling that her missing hand was bunched up into a fist, cramping. Occasionally, she'd even get a charlie horse in the forearm which wasn't there.

Sometimes if she was distracted, or if she distracted herself, the pain would go away. Other days, it was terrible.

etc, etc, you get the idea.

The New Yorker had a recent article on Ramachandran, the neurologist famous for discovering that phantom limb pain wasn't the result of damaged nerve endings in the stump, but of a brain malfunction: the brain had rewired itself to think that a stump was there. What needed to be done was to teach the brain that it wasn't there; or, more immediately, trick the brain into relaxing the fist that isn't there.

He did this by putting a large mirror in front of the person, facing/reflecting the good arm. Looked at from that side, it looked like you had two good arms. You would then clench and unclench your "two" fists, and you/your brain would "see" the other hand (that wasn't really there) also unclenching. You'd feel as if the fist was relaxing, and the cramp would go away.   Apparently, the results were sudden and profound.

So.

I.

I was a little nervous, I don't mind telling you this up front.

I set up the mirror just as Ramachandran had described. At first she didn't really get it, she wiggled her fingers, and nothing was happening.

"What I want you to do," I ad libbed, "is look in the mirror, and imagine that your left hand is doing the exact same thing as your right, simultaneously." I showed her by opening and closing my fists. "In other words, open and close both of your fists."

I barely finished my sentence when her eyes popped wide. "Oh my God. Oh my God."

My eyes popped open, too-- it actually worked!

We did that for a minute, and I asked her to then play a scale on an imaginary piano, 1-2-3-4-5-4-3-2-1, with "both hands."

She started crying. This isn't an exaggeration.   "I can't believe this. I can actually feel my hand..."

This, I thought with immense pride, is awesome.

II.

Well, it's a wonderful story, I guess, and if this was the end of it it would be suitable for Good Housekeeping or maybe one of the medical journals that we pretend to read. Maybe I could sell the story to TV. A Lifetime Original Special: Reflections Of A Physician.

But it's not the end, there are some hard questions to be asked that no one will ever ask:

Sure, it worked, sure, she feels better, sure, she thinks I'm awesome. Why did it take me three years to try something I had known about for ten years with her?

Ramachandran's mirror technique is medical school stuff. Everyone knows it. Everyone. If you don't know it children on the street kick you in the shins. If you were in a coma during medical school then you still would have picked it up from a trillion other places, from Scientific American to Discover to Time Magazine.

Of course I knew the significance of the mirror. Of course I knew how to do it. I just never did. It never even occurred to me to do it.

The mirror occurred to me; doing it never occurred to me. I'll tell you that every single time I saw her stump, the theoretical implications of Ramachnadran's mirror immediately came to my mind, I imagined the mirror. But I never tried it.

Not just me, but it also never occurred to the ten years of doctors she'd seen in her life. Absolutely every single doctor knows about the mirror. Not one tried it.

And it wasn't that I was lazy or didn't care-- I had tried Elavil, Neurontin, Lyrica, Cymbalta-- no, I didn't expect much from them, but I tried them, I thought, why not? Maybe it could help?

But I never even considered using the mirror.

I can't understate this: I was thinking about the mirror in her presence, but never thinking about using the mirror. I wasn't asleep, I wasn't drunk, I wasn't inattentive, I wasn't bored. I was just too much in my world.

So I ask you: did I help her? Or did I make her suffer needlessly for three years?

III.

Without ducking responsibility, what's wrong with medicine today is that it is predicated on providing treatment, not on reducing suffering. Not on solving problems.

The reason it never occurred to me to use the mirror is because the mirror is not something doctors do. Never mind it is fairly safe. What we do is offer treatments. Medications. Procedures. Not maneuvers.

Do you know what every single one of my patients who lives in Flavor Country have in common? They're on Lipitor. That's what doctors do when confronted with the results of smoking. Not nicotine patches or wellbutrin or talking them through becoming a different person. They treat the results. The smoking is an afterthought.

Think about how much controversy there is over using medications that are already approved off label for something else. Where, then, is the cognitive strength to do something that isn't even considered a treatment?

Most residents fantasize about doing something like the mirror on a patient, partly because it sounds cool, but unfortunately really because it puts them on an equal footing with their supervisors. They'll never know as much about Treatment Guidelines For Bipolar XVI as their supervisors, but they can know more about this. This is how they can distinguish themselves.

Once they grow to the point where they are knowledgeable about the Guidelines, then there's no reason to use mirrors.

IV.

Also-- and again not to minimize my own responsibility-- part of the problem with all of the popularizers like Oliver Sacks, NPR, The New Yorker, is they trivialize the information to the point of uselessness. "So that's why the Kurds hate the Sunnis! I'll have a latte." There's a sense among doctors that if it appeared in, say, Wired, it's not real medicine.

When I was a resident I tried the Sacks insights. None of them ever worked. It wasn't either of our fault: there's a big gap between practicing medicine and watching Awakenings.

What I didn't do, of course, is watch Awakenings and then go back and research how I might actually apply it.

V.

Now, all you patients, think about this: there is more than a slight chance that your doctor knows how to help you, but isn't trying it. Maybe it's another medication, maybe it's an intervention, maybe it's information he's simply not telling you. Not on purpose-- it doesn't occur to him to tell you.

Not because he's bad, of course. I don't think I'm bad, not a bad doctor anyway. But hell, if I had to sit with every patient and think out of the box on every issue with them, and individualize the treatment while still maintaining scientific rigor-- drawing not just medicine but from all possible fields that might be applicable to the current problem, being "conscious of the patient's spirituality" not because that's what doctors are supposed to pay lip service to, but because I might be able to use it in a clever manner to obtain results, spending time proportional to what is actually going to matter (like smoking) and less on treatments I am conditioned to provide reflexively--

-- then what kind of a doctor would I be?

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===== ====== ===== The Last Psychiatrist: Randi Zuckerberg Thinks We Should Untangle Our Wired Lives

how hard could it be, none of those circles are actually connected

Randi Zuckerberg is CEO of Zuckerberg Media, which, according to its 10-K, is an iphone. If you have no idea who she is, and you shouldn't, then the answer to your one and only question is yes.

In her considerable free time she wrote a book about social media. Here's a question: why does a woman who epitomizes the online world need to write a hardback book? Could it be there's no money in the online unless you actually own the online? I'm guessing that wasn't in the book. Ok.


I understand she gives a lot of interviews too, I'm sure they're TEDy optimistic and unactionable, but she's apparently an expert, shrug, here is her insight from six years of watching people work at Facebook: social media is a bad thing, unless it's used responsibly, then it's a good thing. Settle in for nuance and shades of grey, all 50 of them.

She thinks it's important to "find a balance" between plugged and unplugged life, a phrase you hear all over the plugged place but has suspiciously avoided scrutiny and is an example of media allowing you to debate the conclusions but forcing you to accept the form of the argument, in this case that a balance is what is desirable.

I'm definitely not advocating a complete disconnect or complete unplug, that's not realistic... But what I am thinking is that people, we've reached this point where we feel like we just need to be always on. Always answering emails 24/7 connected, and the pendulum needs to swing back a little bit for us to reclaim a bit of our own time...

Someone is lying, time to figure out why. While she misdirected us with "pendulum" and "thinking" and "little bit" which are words vicious ideologues use to sound nonideological and "realistic", she substituted the plugged/unplugged balance with work/home balance, don't think I didn't see it. Consequently, when someone/Randi tells you about the negatives of being too plugged in, they almost always blame work emails, as if the things that pay for your dinner are what distract you from dinner.   Really?   If I had to make a sexist yet 100% accurate prediction I'd say that it isn't hers but her husband's work emails that she can't stand at dinner, I'm pretty sure that no husband has ever gotten away with telling his still Anne Taylored wife to put her phone away, "the senior partner will just have to wait, we're about to say grace." I'll cover myself by saying that, indeed, wives do sometimes answer work emails at dinner, however and importantly if this is occurring you can be sure the wife is extremely, extremely bored with everything that happens after 5pm, and this is compared to everything that happened before 5pm which was also *yawns*. "Huh," she soundboards as she one thumbs a text to anyone else, "Obama said that, you don't say, pandering to the flavor profile demo, what are you gonna do."   I'll be first to observe Obama has failed in every imaginable way, but Jesus, if that's your dinner conversation, just Jesus. One of you should cheat just to force the eye contact.

Email is a convenient scapegoat not just because "family time should be protected" but because it gets us out of inquiring what went wrong with our home life that we could ever be tempted by work emails, and the avoidance of this inquiry is highly suspicious, i.e. on purpose. "Honey," she says putting down her Trader Joe's summer salad, "I gotta take this." Only in America does gotta substitute for wanna so we can avoid the guilt. #behavioralgenetics. You may recall industrialization/capitalism/Carousel of Progress's great promise of fewer working hours, and for the most part this has come true, please observe what we have done with our increased leisure time: filled it back up with work. There was some consternation that evil capitalism had forced Target's employees to work all day on Thanksgiving, "no respect for tradition or family time!" But how many of them wanted to be home on Thanksgiving? The customers sure didn't, they were willing to camp out/throw down to get in a store what they coulda got easier/cheaper/faster from their Zuckerberg Medias. "But the store itself has the responsibility to respect tradition!" And only in America do we want the system to force us to do the right thing so we can take the credit. #behavioraleconomics

===== ====== ===== The Last Psychiatrist: Reality Responds To The Matrix

And it says, time's up.

(Part 1: An Action Movie Fairy Tale; Part 2: What Was The Matrix?)

9-11 should have marked the end of the postmodern era, and of the cultural narcissism we were all a part of.

This was an external reality vigorously asserting that it was not going to be the setting of anyone's personal movie.

It caused three narcissistic injuries:

(Recall: a narcissistic injury is when the narcissist learns that his preferred identity is not accepted by others.)

First, it defied the size and time. Some things never get destroyed. Remember WTC bombing 1993? Shrugged off because there was a feeling that the Towers could never really fall; see? They didn't. Neither could Reagan really die; neither could we have a real war (Falklands, Beirut, Gulf I.) There were doomsayers and crackpots, of course. But the real world plodded along averagely.

Interesting: we accused the media of hyping things because what we understood is that such big events can't really happen, but the media needs a story.

We were satisfied with our postmodern explanation because for most people's life spans, nothing gigantic happened. Cold War ended: meh. It was all hype anyway, government bluster, invented to keep us scared and subservient. Not real. Not like global warming.

The narcissist says: if it can't happen to me, it can't really happen. 2500 Americans can't just die in one day.

But 9/11 was different. It didn't respect the rules.

Second, it violated the most important aspect of postmodern narcissism: story. Not only was the attack a surprise-- no warning, no buildup, no exposition, no rising action-- but even the characters were a surprise.

At least if it had been the Russians, or even aliens, it would have followed a previously understood narrative. Has anyone seen this movie before?

We didn't know they even existed. Tali what?   Did anyone know the backstory? Was there a movie with them as the bad guys? Back To The Future!-- wait, weren't they Libyans?

Turns out we are just bit characters in someone else's movie.

Third: we were revealed to be powerless. No heroes. No one knew kung fu. Who was there left to fight, anyway?

Were they any heroes? Anybody? How about... firemen?

Ultimately, 9/11 contradicted The Matrix. We weren't more than we appeared, but less.

We were so psychologically paralyzed that the very first thing we did was change the language to minimize the narcissistic injury, the discovery that other people were able to affect us. We called Oklahoma City a bombing. This was just a date.

On one sunny, cloudless Tuesday, postmodernism was obliterated. Two days short of Neo's thirtieth birthday.

Narcissistic Injuries Result Always In Rage...

If you are under 23, this probably won't have the same significance: the government, the media, and the American public were seriously debating the use of nuclear weapons.

We got Iraq, say whatever else you want. Right or wrong, it would never have been possible pre-9/11.

... Or Denial

But 9/11 didn't take. I cannot explain this. Within a year, two years, we were back to the same old narcissism. "Everything changed after 9-11" turned out to be exactly false. The stock market went back into familiar bull run mode, and in 2006 Time named "You" it's Person of the year, a laughable move at any time in history, let alone post-9/11 and waist deep in Iraq.    9/11 should have changed everything. It changed nothing.

And The Matrix is Good For Another Two Sequels

So we went back to the teachings of The Matrix. Back to individualism, back to defining yourself based on what you believe rather than what you do. Self-entitlement, self-fulfillment, and until then the thousand yard stare of hope. The ideas in The Matrix should have given us ten more years of narcissism, until the "next thing" came along. And, indeed, it did.

You might say that the Great Recession we're in now should end postmodern narcissism. Nope. Amazingly, all I hear and read are calls for punishing those who got us into this mess (Wall Street), "fixing the system," "solving the housing crisis." People are waiting for things to "get back to normal." People: this is normal. The past twenty years-- easy credit, college for everyone that leads to a job at Starbucks, unemployment under 6%-- that was abnormal. We associate the word "unemployment" with steel workers, but do you think any economy not top heavy with credit can afford to pay 600 extra Starbucks stores worth of baristas $8/hr? Or computer programmers $50k? Don't yell at me-- I'm not saying they aren't worth it-- I'm saying this economy cannot, and could never, afford it.

I know, greedy companies are outsourcing to India because they want to maximize profits. You say that thinking that if they stayed in America, they'd make less profits. Wrong. They'd close.

"You don't know what you're talking about. Why would Toyota build plants in Alabama and hire American workers if it wasn't profitable?" Because it gets them two senators and a bunch of congressmen, that's why.

Instead of having that discussion, the one we're having is whether we should tax AIG bonuses at 90%. I know I'm alone in this, but someone has to say it: this is idiocy. Sure they don't deserve those bonuses, but really, is this the best use of Congress's time? Really? "But it's about perception." Isn't it time we focused on something more than perception? Isn't our obsession with perception exactly what is wrong with us?

So: two huge historical realities have had no impact on our cultural narcissism.

This is further support to my contention that meaningful cultural change can't happen to a society while it still lives. It requires a change in generation, in biology.

Thankfully, we are setting them up very nicely.

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===== ====== ===== The Last Psychiatrist: Real Men Want To Drink Guinness, But Don't Expect Them To Pay For It

the reason the bubbles go down is because of the drag created by the bubbles rising up the center.
yeah, like a metaphor.

Click this ad. It's great, the internet told me so, it says it represents something good about humanity. You're going to cry and feel good about the future and then consider ordering a Guinness. That is, unless you already like Guinness and then you're going to have a totally different reaction, like switching to Belhaven.

===== ====== ===== The Last Psychiatrist: Real Or Fake? (Fake.)

a corollary to Parkinson's Law of Triviality

If you have trouble following my rants about misdirection and manipulation in the media, this is a good example of the mechanism. Don't be fooled by the triviality of it.

It's a slideshow called "Real Or Fake." Look closely.

FYI: the answer is real.

You can see at the bottom the rest of the people are Rihanna, Pam Anderson, Jennifer Love Hewitt, Playboy Playmates, etc.

But rather than the slideshow being about the obvious-- about the thing that got me to go to it-- it pretends to be about something else:

Ooh. Tricky. And it continues in this vein:

Get it? Bait and switch, without the switch.

You are enticed to look at it because it makes you think it's about famous women's boobs. But CBS can't just become the CW, it has big brand advertisers it needs to satisfy with its high level of integrity. Acura isn't paying just for eyeballs, it's paying for positioning and loyalty. "The kind of person who likes CBS is the kind of person who likes Acura." And vise versa. So the captions afford it plausible deniability even as they pull in the internet clicks.

And there are plenty of clicks. Go to the CBS site-- the same slideshow is playing on CBS affiliates throughout the land-- and scroll through the 27 slide show (turn off your adblock.) Every new slide refreshes the ads. So if each ad pays $x per 1000 displays, the slideshow has the potential to bring in $27x.

It's the same with the NYT or any other site that has multiple pages to a single article that you need to click through-- all of those allow the ads to refresh.

So an article of $x can potentially generate $4x.

II.

In Network, the news division simply didn't bring in the revenue like an entertainment show did; but it was argued that the news division is too important, profit be damned. Is that realistic? No. It makes tons of money for the network.

The primary motive for the media company (not the individual news outlet) is to draw in ad money and traffic. So an unwatched show on CBS like the Miss Universe Pageant generates tons of money for CBS in other ways (e.g. Access Hollywood. "You'll never believe what happened!" I didn't think I cared what happened, but I guess I do?)

Same with the news. The news can legitimize a story sufficiently to allow it to get play everywhere else on the network.   "CBS News is reporting that Mel Gibson..." Or it can play in the reverse. Rolling Stone magazine is expected to have the naked cast of True Blood on their cover, CBS News couldn't get away with that. Solution? CBS News does a story about the Rolling Stone cover, which in turn legitimizes it further.

All "shows" are responsible to their advertisers (not the public) but in a way that circumvents clear accountability. Does Acura really want a fake boobs story on CBS? No. But would it allow a "how celebrities deceive their public?" story? Go get 'em.

So the news wants to give you pornography, but it still has to pretend it is giving you information.

III.

For example (British paper The Daily Mail):

So why would a newspaper want to publish a story about a woman upset about breastfeeding bullies?

They wouldn't; the only part of the story that makes it interesting to them is that the bully is supermodel Gisele. Without the link to Gisele, the article has no draw.

But even so, why would a paper care what some mom thinks about what Gisele says? It would only do so if the "mom" was some kind of a celebrity herself already; and Denise is apparently some kind of celebrity over in the UK, having judged a talent show and been naked in public.

Meanwhile, how does a D list celebrity keep herself in the spotlight post baby? Not by talking about breastfeeding (meh) but by attacking Gisele (oooohhh!)

For clarification, the real reason Denise doesn't breast feed is:

"I can't be sitting in Starbucks and breast feeding, because they (photographers) are taking pictures."

That's media today. The story is used by Denise to keep herself in the spotlight and then by the publisher as three kinds of linkbait: Denise, Gisele, and breastfeeding.

The point that must be emphasized is that the purpose of the story is to get you to go there. That's it.

III.

I've chosen silly examples to make the method obvious and the purpose clear.

A more subtle example of this manipulation is the current controversy over the "Mosque at Ground Zero." This is manufactured controversy if there ever was one, but instead of being being manufactured by politicians for political purposes, it's by media for the purposes of bringing in clicks.

Never mind it's not at Ground Zero. It's two blocks away, well guarded by St. Peter's Church, The Department of Health, and the University of Phoenix. Feel safer? Furthermore, the Amish are stationed right next door.

And never mind that it is already a mosque. Another mosque four blocks from Ground Zero got full, and so they were having services at the Burlington Coat Factory-- the site of the proposed mosque.

The only thing that matters is keeping the controversy alive so that people go to the story. Fox will tell you it's at Ground Zero, CNN will be careful to mention that it's only near Ground Zero, but anyone is free to use the controversy to bring in the clicks:

etc.

Interestingly, the CS Monitor gets it exactly right, I'm sure by accident:

----

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===== ====== ===== The Last Psychiatrist: Recent Trends in Stimulant Medication Use Among U.S. Children

is this a joke?

A study, Recent Trends in Stimulant Medication Use Among US Children finds, surprisingly, that 3.5% of kids under 18 got stimulants, vs. 2.4% in 1996. Holy crap!! The reason this is surprising is that 3.5% is about 10x smaller than I thought it was. American Journal of Psychiatry? Did I move to Romania?

Then the article informs me that I am both racist and color blind: most stimulants are going to white kids (4.4%), not black kids (3%), and about hispanics I was WAY off, I was certain the number was close to 133% but apparently it's only 2.1%. Huh? Does this study include the 48 states of America that have Americans in them, or just Guam and parts of the Virgin Islands?

The article pretends to be shocked by this "steep increase," and then tries to explain it by putting some nouns and verbs next to each other hoping you'll be impressed:

The significant increase in stimulant utilization in racial and ethnic minorities and low-income families indicates an increased recognition of ADHD... social and cultural factors continue to play a significant role in ADHD treatment utilization. Parents of Hispanic and African-American children are less likely to report ADHD than parents of white children...(15)

That last sentence, referenced with "(15)", sounds like the conventional wisdom I heard in residency: "African-Americans don't like to admit depression", excluding those in the packed waiting room. (1) But when I eventually (2) found study "(15)" I was totally not surprised to find it did not say parents are less likely to report ADHD. "(15)" was a survey of parents asking them if they had been told by a doctor or school that their kid had ADHD.

The reason that 3.5% of kids are on stimulants is that their doctor neglected to give them Risperdal. The kid who got Ritalin at age 6 and it helped carried that Ritalin into the teen years, hence the growth among adolescents; but any new kids coming through the pipe don't get stimulants, they get something else, by which I mean everything else.

Note the big jump at 6 years old, from 0.1% to 5.1%. Yes, certainly symptoms become more prominent, but also they become prominent at school; schools have an interest in medicalizing the problem, both practically (calm that kid the hell down) educationally (diminished expectations) and economically (schools get more funding.)   Stimulants are the natural first line drugs. Well, they were, anyway.

This ridiculous article pretending to be amazed at the increase in stimulants is there to prevent the heart attack you'd experience if you looked at another study that has a graph in it:

Unless you believe bisphenol-A or global warming is changing the genetics of kids born after 1990, then the correct and terrifying way to interpret this graph is that one in every four kids is considered by adults to be in need of psychiatric treatment; and only 3.5% get put on stimulants. The other 20% we can assume are receiving psychoanalysis.

Maybe they need the meds, maybe they don't, the question is if these are the same kinds of organ donors that existed in 1896, what happened to them before psychiatrists? Did they eat each other? And if they are, in fact, more "psychiatric" than they were in 1896 and bisphenol-A isn't to blame, then what is the other possibility?

And as that huge number of psychiatric patients grow up to become either unemployed adults, or at least the children of unemployed parents, will they

a) experience spontaneous and permanent remission of symptoms
b) be treated with psychoanalysis
c) .....

-------

1. The conventional wisdom is backwards. The black patient isn't resistant to admitting he has depression, he is resistant to the white doctor's attempt at labeling him depressed, and consequently marginalizing him, diverting attention away from the social factors over which the doctor is nervous to discuss and powerless to change. "You have depression" is the nimble dance around the question of whether a white doctor can understand a black patient's life. It is a delicate thing to say to a black woman that perhaps her man isn't worth a damn, as she just said out loud to you but you're not sure if you're allowed to echo back, maybe these kind of relationships are culturally appropriate? It's tough to know when most of your information about black people comes from Martin Luther King quotes and The New Yorker.

Lacking any common language to bridge racial, economic, or sexual divides, clinicians hide behind the invented terminology of psychiatry. Medications become the physical manifestation, the proof, that the language is real.

2. Whenever I see a reference to a statement that seems insane to me, two things will be true:

It will take me as long to get the study as it did to conduct the study, i.e. 45 minutes. No hyperlink. No free access. Then I have to go into the university's PubMed, which takes me through three windows to Science Direct or some other outlet. Why, oh why, can't I just click "(15)" in the original paper and immediately see it? Because:
It will turn out to be actually insane, and the only part of the reference that will support the statement will be the title.

See also: The Rise And Fall Of Atypical Antipsychotics

===== ====== ===== The Last Psychiatrist: Reciprocal Determinism And Why Punching People Out Is Way Cool

A quick addendum to my previous post on the "Psychological Uncertainty Principle."
A reader pointed out that some of this is explained by "reciprocal determinism", which basically means that you respond to your environment, but then force a change in your environment which further changes your behavior. For example:
"Girls don't like me. Girls don't like me.   Girls don't like me." Repeat x 100.

So a girl thought she liked you, but then met you, and now decided you're a nutter. So she bolts.
Now you have proof girls don't like you.
It sounds like reciprocal determinism says who you are affects your environment, which then affects you.
That's wrong. In the above example, it wasn't ever true that girls didn't like you. You made it true. You changed your behavior, somehow, that made it so that girls don't like you. You received some gain from making it true that girls didn't like you-- perhaps it helps you avoid intimacy, etc, etc.
So your identity never enters the equation. Reciprocal determinism is about behavior, not identity. Albert Bandura (the originator of this concept) was responding to Skinner's behaviorism.
Wikipedia's article on reciprocal determinism is a perfect example of this exactly wrong use of the concept. They describe how low MAOA enzyme can cause you to be antisocial. In fact, it is the opposite: having low MAO-A does nothing, but having high MAO-A seems to be protective. The reason people became antisocial (synonymous with criminal) in those studies was that they were abused-- in essence, they imitated the behavior.
The experiment Bandura is famous for speaks to my point about the absoluteness of your responsibility for your identity: kids watched adults beat up a bobo doll, and were then put in a room with a bobo doll, and, surprise, the majority then imitated this behavior, even using the same hitting techniques and repeating the same phrases the adults did. Nothing genetic or even environmental affected this outcome-- almost all the kids did it (and almost none of the control kids who didn't watch the adults beat up the doll).
So watching the Matrix causes kids to go Columbine? Bandura would have said yes. But oddly no one ever wonders why then the cooking channel doesn't result in more pies, or why porn hasn't prompted rampant depilation. Bandura's theory of reciprocal determinism required a key element: reinforcement. There has to be a gain in the imitation, in the identification. You may have "learned" the violence by watching it, but you won't display the violence unless there is some reward-- it isn't just a reflex, some part of your core identity. You decide to imitate it, because it rewards you. How? "I want to be just like my Dad" (except he beats Mom.) "Neo is so cool." (Didn't he kill all the human security guards?) "Thug life!" Etc. Note that no one ever imitates the violence of, say, Gollum. Want to know why? Because Gollum never scores any chicks.
So once again, you pick who you are. Or: you picked who you are, how you behave, whether you know this or not. So now ask: why did you pick this person, this identity? And what is preventing you from changing any or all of it?

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===== ====== ===== The Last Psychiatrist: Recollections Of Your Parents Before And After You Have Children

Did you know my blog has more readers than Psychiatric Times and Family Process combined? That sad fact compels me to refer you all to something excellent in both.

For you parents out there (especially women):

Before the birth of your first child, what was your recollection of your own childhood relationship with your parents? Were Mom and Dad close to you, distant, domineering, warm, etc?

If the question was then asked four years after the birth of your first kid, how would your answer change, if at all?

I.

Jerry Lewis, MD, writes in Psychiatric Times about a study he did in 1995. He interviewed young couples before the birth of their first child, and four years after, about their recollections of their own childhood.

He found that having a kid did not change their recollections, with one single exception:

A number of the female participants changed their recollections of their fathers from positive to negative. After 4 years of parenting, they no longer recalled their fathers as being as affectionate and supportive during their childhoods as they had been before the birth of their child.
I would have guessed the opposite, that most women would think better of their fathers after four years of motherhood: "wow, being a parent isn't easy, I have new respect for my Dad."

So why would a subgroup of women think worse of their fathers after they had kids? (Or: why would they think better of their fathers before having a kid?)

Perhaps women thought, "wow, look at all the attention and love I give my kid, my Dad never did that."

II.

That would be my guess; but Lewis found a different reason.

...we found a clear pattern, and it had to do not with the female participants but their husbands. The women who changed their recollections [more negatively] had husbands who were depressed, who helped little with parenting, and who were observed to be less sensitive to their children than other fathers.

Hold on-- why wouldn't having a bad husband make you appreciate your Dad more? Joe is mean, my Dad wasn't. If you think your husband is detached, uninvolved, and moody, why wouldn't you idealize your Dad in comparison?

The women with depressed, unhelpful husbands did not report lower levels of marital satisfaction; rather they were maintained at high levels. One interpretation of our data was that the women's more negative memories of their fathers served the function of minimizing (or denying) their husbands' failure to be as helpful as needed. If this is all that can be expected of men, then I can no longer recall my father so positively!

So his theory is that these women selectively remembered negative things about their fathers in order to make their own husbands look better in comparison.

Let's say this is correct. It suggests a bigger problem: are these women willing to do this at the expense of their child who still has to live with him as a father?

III.

The facts are these:

before having a child, women thought highly of their fathers and their husbands/marriage.
After birth, they continued to think highly of their husbands, but worse of their own fathers.
The husbands were observed by their wives to be less sensitive to the kids than other fathers and helped less with parenting.

These women were not in complete denial about heir husbands' shortcomings-- they put it on the questionnaire. But they were just as satisfied with their marriages in spite of the fact that their husbands were bad fathers. Put another way: that their husbands were bad fathers didn't make them less satisfied with their husbands-- it made them less satisfied with their own fathers.

These particular women were willing to demote the significance of both their own fathers and their own children in order to maintain the illusion that they had a good marriage.

IV.

But put all this aside. Lewis's article is about the larger issue of historical narrative, constantly being revised to suit the demands of the current ego. The above women needed to affirm their husband's worth, so they changed their recollections of their fathers.

That's one explanation, but consider for a moment a different possibility: that changing your memories changes you.

Merely reading that sentence gives you pause. The man who holds onto childhood anger; the person who doesn't forget a certain grudge, people who "remember where they came from"-- these things anchor identity, keep you the same. I'm not making a value judgment, I'm describing a process.   We believe that growing, or therapy, brings us to a point in our lives where we can reinterpret memories. But simultaneously, the act of reinterpretation changes us.

You don't just look back on your parents differently when you become an adult. You also become an adult when you are able to look back on your parents differently.

Every moment of every day, you decide who you are, and you decide how things will be remembered. Memory isn't a hard drive; it's a text editor.

When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.
That should properly read: when I became an adult, I put away childish things. Then I became a man.

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===== ====== ===== The Last Psychiatrist: Refusing To Answer The Feds

you're not the boss of me

Paul Lucaks wrote a post called, "I Am Detained By The Feds For Not Answering Questions."

Imagine the rest, but here's his first sentence:

I was detained last night by federal authorities at San Francisco International Airport for refusing to answer questions about why I had traveled outside the United States.
There's a few ways to go with this, but here's a start: this article was written 4/24/2010. It received 700+ comments. He wrote a follow-up article to this yesterday.

"Why were you in China?" asked the passport control officer, a woman with the appearance and disposition of a prison matron.

"None of your business," I said.

Her eyes widened in disbelief.

"Excuse me?" she asked.

"I'm not going to be interrogated as a pre-condition of re-entering my own country," I said.

In other words, this is what he was thinking about on 9/11.

II.

The easy interpretation is that he is/is not an idiot for baiting the border patrol. Yes, it's his right not to answer questions (or not to show ID at security, which I tried), but for a man who has had 5 months to reconsider his position he's apparently learned nothing.

The real question, however, is why he did this.   The only way this form of protest is meaningful is if it is done in public. In other words, the only reason for him to do this is so that he could tell us about it.

He thinks this is a battle between himself and the border patrol as representatives of the US Government. That would be a gigantic example of not seeing the other person, not seeing their perspective. That border agent isn't a representative of the government, he's an employee of it.    Look at them closely-- they don't look like Dick Cheney at all.   These aren't arms of the Executive Branch that thrive on suppressing the human dignity of liberals, these are people who enjoy Schlitz and masturbation. Just like any other decent American. You can't change anything by yelling at him, and Lukacs knows that. And he doesn't care. Lukacs is the main character in his own movie, and he is yelling at the character designated as "mean border agent." Note that he didn't bother to take the names of any of the fascists who were mauling his civil rights. In the credits, they will appear as #1, #2, #3, etc.

Paul doesn't think he is the best or smartest or sexiest character in his movie, but it is quite evident that he thinks he is the only one.

III.

This isn't to say he's a narcissist; in some other situations he may be quite empathic and contemplative; but power dynamics trip him up emotionally, so he regresses. If you read his article and get the feeling he's behaving a little like spoiled toddler, there you go.

IV.

Lukacs claims they have no power over him. But Lukacs doesn't understand at all how power works; he is confusing law and power, and that confusion bought him an hour in the chairs. "The Feds" have complete power over him. The fact that he doesn't understand how utterly manipulated he was demonstrates this. The moment they "led me into a waiting room with about thirty chairs" they already knew he wasn't a threat. They knew he was just a troublemaker, specifically making trouble for the officers who were unlucky enough to have him in their line. They ran his name in a federal database. Maybe they did a google search as well, which would return his photo and reveal that he's little more than some blowhard lawyer.

But it's at the moment they decide that he isn't a threat that the demonstration of their power begins, and he complies. They tell him to sit, and he sits. They tell him to follow, and he does. They know they can't legally do anything with him, so they play with him. "Six other people were waiting." What did he think those six people were they doing there? They were just like him. They didn't answer the questions. Lukacs writes, "This must not happen often, because several of the officers involved seemed thrown by my refusal to meekly bend to their whim." Setting aside that asking the questions they are instructed to ask isn't a whim, and that not everyone who doesn't want to be inconvenienced because they value their time is "meek", he is incorrect. It happens often enough that they built a room for it, in every airport. With lots of chairs.

Lukacs gets it wrong because he thinks he has disrupted the process by refusing to answer. Wrongtanomo. That is the process. Just a slightly less-used branch on the Process Flowchart. The room and chairs are there because the government assumes that people will exercise their rights and not answer. The room is exactly the same as the line he was in at first, except for a different group of people. The room is there to remind you that it costs you something to enforce your rights (time and aggravation) and costs them nothing to impose that cost on you.

I'm not supporting or endorsing what they did to him any more than I support what he did. But understand this, it makes no difference to the agents, this game. They punch out at the same time everyday. How they spend their 7.5 hours at work is largely irrelevant. Maybe some guy was a nuisance for an hour or two. Whatever. They're still back home in time to get annoyed by their kids.

Lukacs thinks he is fighting the government, and the government is fighting back. In reality, the government doesn't feel this fight at all. Border agents do; I'm annoyed at him and I'm at home, I can imagine how they felt. So they took what power they had, and used it.

V.

There's a subtle but powerful Strangeglovian brilliance to the system in place. By giving the officers this permission to do what's necessary-- it subtly shifts Lukacs grievance away from the government's policy to the easily defended/"solved" actions of the agents on the ground.

This is similar to what happens at G8 riots or political demonstrations - the demonstrators clash with police, literally instigating fights with riot police sometimes, thinking it will further their cause. But the police don't represent the interests behind any political agenda any more than the demonstrators do. They are there simply to maintain order while the protesters exercise their rights. The protesters' real grievance is with people they don't dare fight in any way (including not buying their products). So they use the supporting cast of police officers as some kind of character exposition in their movie: "in this scene, I'm a protester fighting the bad police."

Governments know this, this is the structure of power. The more cops on the street maintaining order, the more likely the situation will decay into disorder as protesters confuse challenging the authority of the policymakers with challenging the power of the police. So they fight, and the media goes with the story that's for you: unruly protestors clashing with police, pick a side, and thereby quietly removing from the story the real and legitimate political grievance that initiated the protest in the first place.

What Lukacs doesn't realize that his legitimate desire to challenge the authority of the government was transformed into a confrontation over the reasonableness of the use of the government's power by its agents. He isn't defending any right great or small, he's simple playing out his part in feeding the machine.

VI.

What would Lukacs have done if the border patrol agents were all robots? Narcissistic thinking never works on robots. A person may completely ignore how another person is thinking, but everyone always understands a robot's perspective.   With robots, it is explicitly understood that they are operating on a flowchart, that they have a definite way of thinking of their own that has nothing to do with who you think you are. You can't force your thinking on a robot. So Lukacs wouldn't dare disobey anything upon which he cannot impose his will. That's why he's fighting border agents, and not the government.
---

Co-written by Pastabagel

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Relative Income Inequality

did i make things worse?

Part 1
Part 2

Reiterated: Wilkinson finds that one judges equality against people in their own nation; and absolute income is not nearly as important as relative income inequality.

we looked at life expectancy, mental illness, teen birthrates, violence, the percent of populations in prison, and drug use. They were all not just a little bit worse, but much worse, in more unequal countries.

...what matters aren't the incomes themselves but how unequal they are. If you're a more unequal state, the same level of income produces a higher death rate.
It's such a simple argument that it is easy to think he's saying something else. He's not talking about an inability to access basic services or buy food and shelter-- not "haves" and "have nots" but the "psychosocial" (his word) effects of inequality.

There are problems that we think of as problems of poverty because they're in the poorest areas of society, but a country like the U.S. can be twice as rich... and the problems are no better even though Americans are able to buy twice as much of everything as the poorer developed societies.
The income inequality matters because we are a social species and relate not to absolutes but to each other in our own nation.

So, is he right?

Of course he's right. You don't need any of his data to know resentment is always relative to the other, frustration is synonymous with a impeded will, and that both of these exact a biological and psychological toll. I don't need anyone to tell me that massive executive pay drives people bananas. And as I've hopefully made obvious by this point, most people's anger about policies, politics, and problems are really about our relation to some other group of people.

But slow down. The mistake everyone is making is conflating the problem-- income inequality-- with the proposed solution-- income redistribution.

II.

First, while the hard data point to "income inequality" because it's the only measurable statistic for the real issue of income justice, i.e., getting what you deserve and deserving what you get. When people talk about the social effects of income inequality in America, they always bring up CEOs but never, not once, ever, bring up Warren Buffet. Or baseball players. Or the Kennedys. Or Sandra Bullock. As much as Sandra Bullock drives me insane I have never set fire to a trash can or impregnated a teenager because she made what is obviously way too much money for agreeing to be in the worst movies ever scripted by spider monkeys.

However, we have some (obviously warped) sense that these people deserved their incomes. So what we're really wanting isn't income redistribution but a sense of distributive justice.

Well, good luck on that one: who is going to be trusted to redistribute? "The government" isn't a spirit, it's a bunch of people that seem to be selected for infidelity. And people Americans are rightly suspicious of the criminal justice system; why would the distributive justice system be perceived to be any more fair? It doesn't matter a lick whether it is actually fair or not because it will be filtered through a lifetime of prejudices and cognitive biases. As one rambling fool put it, it's the Stroop test applied to public policy.

I've not seen anyone bring up a point that will be obvious the moment I say it: rich people can get angry, too. If people get angry because they don't have what they think they deserve, imagine the anger that will manifest when people have things taken away from them. Don't yell at me: it matters not at all whether "the rich" are entitled to their anger or justified in their purchase of a Cessna, only that it is a fact that they will be angry.

You can't pretend social unrest only comes from the bottom up; when a group of feel unfairly branded as "the problem" by the likes of people whom they believe have never actually produced anything (i.e. congressmen), and what they feel they've earned taken from them, well, they won't be breaking store windows and flipping cars over, but your society will be transformed all the same.

Again, I am not justifying their anger, I am warning against what you think is so obvious a solution. I am describing reality: rich people can buy guns, too. And Congressmen. This is a fight that you cannot win, not here and not for at least two more generations.

If you attempt income redistribution, not only will you fail, the country will bury you for 25 years. It happened to Jimmy Carter. It will happen again.

III.

The second reason income redistribution will fail is that you change its value by redistributing it.

If you run Wilkinson's book through Babel Fish, you see that when he writes "income inequality" he actually means "relative inability to participate in society." In other words, the disparity isn't income, it's consumption.

Income inequality seems to explain why America has more social ills than, say, Costa Rica but it's because income means something completely different to Americans than it does to Costa Ricans.

To any nominally poor nation-- take your pick, from African subcontinent to nearly integrated industrialized Romania-- income is only a supplement to an existence. In America, it represents expectations, potential, identity, everything. Even the least materialistic American makes judgments about other people based on this income, even if the judgments are inverse ones ("the rich are bad" etc) or about himself ("I'm not like other Americans, I don't need an income.")

Income represents the potential for consumption, and this potential is the measure of social equality.

Wilkinson strolls right up to this point, has his face bitten off by it, and walks away oblivious:

Status competition causes problems all the way up; we're all very sensitive to how we're judged. Think about Robert Frank's books Luxury Fever or Falling Behind, or the great French sociologist Bourdieu--they show how much of consumption is about status competition. People spend thousands of pounds on a handbag with the right labels to make statements about themselves. In more unequal countries, people are more likely to get into debt. They save less of their income and spend more.
That's what his data actually shows, but he falls back on income inequality. Status competition, personal branding, attempts at self identification. Even nearly perfect redistribution of income will not affect these social ills because people will find something else to set themselves apart from the rest. High school students manage to create a viciously unequal society that drives some kids to suicide and others to Columbine and others to group sex and it has nothing to do with income at all. Or are we still blaming genetics for all that?

IV.

When I tell you that narcissism is the biggest epidemic this generation faces, I'm not looking to get on Oprah, I mean it. Any tentative political solution-- redistribution of income, modification of entitlements (either more or less), focusing on education, whatever-- while these are all noble approaches that likely will have some immediate impact-- long term all of them will fail. All of them. The problem is deeper than incomes, it is expectations, and you can't redistribute expectations.

You could hand every American $10M in gold bullion right now, free and clear-- you could take it right out of a CEOs pocket and call it social justice-- and nothing will change except that they will drink more.

I'm not constructing a conservative argument against a liberal policy, I'm not choosing an economic ideology; I am taking a strictly realist's perspective that income redistribution will fail. And it will fail also in China and in Brazil and yes, even Scandinavia. Everywhere, it is inevitable.

There's a very specific reason for this, Wilkinson hits it but refuses to pursue it to its conclusion; instead, he falls back on income inequality:

If you grow up in an unequal society, your actual experience of human relationships is different. Your idea of human nature changes. If you grow up in a consumerist society, you think of human beings as self-interested. In fact, consumerism is so powerful because we're so highly social. It's not that we actually have an overwhelming desire to accumulate property, it's that we're concerned with how we're seen all the time. So actually, we're misunderstanding consumerism. It's not material self-interest, it's that we're so sensitive. We experience ourselves through each other's eyes--and that's the reason for the labels and the clothes and the cars.

(Part 4 soon.)

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===== ====== ===== The Last Psychiatrist: Ritalin Causes Cancer?

An eye-opening study from some Texans.
18 kids, newly diagnosed with ADHD, started the study, only 12 finished. They showed up on day 1, and blood was taken. The kids were then given Ritalin (methylphenidate) 20-54mg/d, as part of ordinary treatment, for three weeks. At the end of three weeks, another blood sample was taken. The bloods were evaluated for cytogenetic abnormalities.
In every single case, the frequency of chromosomal aberrations, sister chromatid exchanges (SCE), micronuclei, and nucleoplasmic bridges were all dramatically higher than at baseline. Not a little higher-- massively higher.
The authors had, in their introduction, summarized the absence of substantial evidence (or actually even studies) for carcinogenicity or mutagenicity, except one long term (2 year) high dose study in rodents-- it gave them hepatocellular carcinoma. But there has been nothing done in humans.
There are some problems with the study, beyond the obvious small sample size.
First, there's no control group. The assumption is that the only new factor over the three months of the study was the taking of Ritalin, so that is the likely culprit. Of course, it is certainly possible that something else occurred during those three months that could have caused this effect, such as a new illness, new meds, taking up smoking, etc. In all twelve people. At the same time. Sure, it's possible.
Second, the pretreatment group actually had less sister chromatid exhcanges than are expected on average. In a follow-up letter letter , the authors indicate that the known average frequencies of SCE are actually based on adults, not kids. Do kids have lower frequencies in general? Maybe.
The authors in that same letter also observe that despite the perception that there has not yet been on observed link between Ritalin and carcinogenicity, in fact
"the national toxicology program (NTP)—CERHR expert panel report on the reproductive and developmental toxicity of methylphenidate, indicate that only one study addressed the carcinogenic risk of methylphenidate treatment in humans... conducted by screening pharmacy and medical records, indicated that there was no increase in reports of cancer in a small number of patients taking methylphenidate (only 529 patients)."

I looked up the cytogenetic effects of amphetamines.
One study found methamphetamine exposure correlated to frequency of  micronuclei and SCEs in humans (though, in hamsters, this effect was due exclusively to methamphetamine itself, and not its metabolites; and free radical scavengers also reduced this effect).
An old 2 year rodent study found decreases in number of neoplasms when given dl-amphetamine. Another study found a similar reduction, especially in pheochromocytomas, pituitary adenomas, and breast adenomas.
But again, these are rare studies, and this one here is the first done, prospectively, in humans.
What is astounding to me, apart from the obvious, is that no one knows this article. It has not been referenced in any subsequent articles. I can't find one psychiatrist, academic or otherwise, who has even heard this. They all look at me blankly: "Really?"
Yet, simultaneously, psychiatrists live with complete confidence that Ritalin is safe. They've never checked the known information before, of course, so what allows them to be so confident I have no idea; and they certainly don't run Medline once a month "just to keep up with all of science"-- but they're sure of what they know. Not even an empty patronizing nod to "but of course, our knowledge base is expanding..."
The point is not that Ritalin is unsafe. This study could be a load of crap, for all we know. But shouldn't psychiatry have at least heard of this study? What is the mechanism to disseminate this kind of information?  How long does it take for something like this to hit the psychiatric press? In other words, given psychiatrists' arrogant confidence, how do they believe they would be informed of new developments? They don't really read psychiatry journals. They certainly aren't going to read cancer journals.
9/5/06 Update Further info suggests this may be a fluke.

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===== ====== ===== The Last Psychiatrist: Ritalin Doesn't Cause Cancer(?)

Supplement to this earlier post: Ritalin Causes Cancer?
Follow-up study from a different group finds no clastogenic effect of Ritalin:
In summary, MPH was found to be non-genotoxic in all bacterial assays reported [5] and [8], in all in vitro mammalian assays conducted in compliance with current guidelines (5, present study) and in two in vivo bone-marrow micronucleus studies (5, present study).
It sounds like the El Zein study was a fluke (and thank God, too.)
But it doesn't resolve my main point: how is the average psychiatrist going to know about these findings? Is there a mechanism for new information? Is there somewhere, hell, even a blog or listserv, where psychiatrists can at least get the headlines of important articles? But that requires someone to write this all up, and I don't know anyone who has that amount of funding or time to spend on such an endeavor.

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===== ====== ===== The Last Psychiatrist: Rutgers Student Commits Suicide (After (Being Taped) (Having (Gay) Sex))?

this could go either way

CNN:

said to be devastated when his private sexual encounter with another man was secretly taped and streamed online...

I'll open by saying that, on the face of it, this is a tragic story. There's the power differential, and the idea that a woman could be part of the bullying (for lack of a better word.) The subtext that gay sex isn't sexy, but funny; and, of course, no matter what happened, suicide is horrible.

But while the media has clearly established the cause and the effect, it doesn't seem so clear when you follow the events. The biggest inaccuracy is that he didn't just find out he was taped, he knew about it already.

I.

On 9/21, at 7:22 am, he writes on a message board, "so the other night..." and describes his roommate turning on a webcam, etc. Dharun's twitter confirms the sex and the taping happened on Sunday, 9/19, between 6p and midnight.

However, he doesn't sound extremely upset; he talks about working things out with his roommate, his roommate isn't a bad guy, etc.

so the other night i had a guy over. I had talked to my roommate that afternoon and he had said it would be fine w/him. I checked his twitter today. he tweeted that I was using the room (which is obnoxious enough), AND that he went into somebody else's room and remotely turned on his webcam and saw me making out with a guy. given the angle of the webcam I can be confident that that was all he could have seen.

so my question is what next?

I could just be more careful next time...make sure to turn the cam away...
buttt...

I'm kinda pissed at him (rightfully so I think, no?)
and idk...if I could...it would be nice to get him in trouble
but idk if I have enough to get him in trouble, i mean...he never saw anything pornographic...he never recorded anything...

I feel like the only thing the school might do is find me another roommate, probably with me moving out...and i'd probably just end up with somebody worse than him....I mean aside from being an asshole from time to time, he's a pretty decent roommate...

the other thing is I that don't wanna report him and then end up with nothing happening except him getting pissed at me...

Then on 9/22, at 4:38 am-- ???-- he writes that he had asked his roommate to use the room again, but this time saw the webcam in advance.

so I wanted to have the guy over again.

I texted roomie around 7 asking for the room later tonight and he said it was fine.

when I got back to the room I instantly noticed he had turned the webcam toward my bed. And he had posted online again....saying...."anyone want a free show just video chat me tonight"...or something similar to that....

soooo after that.....

I ran to the nearest RA and set this thing in motion.....
we'll see what happens......

I haven't even seen my roommate since sunday when i was asking for the room the first time...and him doing it again just set me off....so talking to him just didn't seem like an option....

meanwhile I turned off and unplugged his computer, went crazy looking for other hidden cams....and then had a great time.

Someone writes back to him a minute later:

You may want to take a screencap of his twitter feed if you want to go the legal route just so you have some evidence of his activity.

===== ====== ===== The Last Psychiatrist: Sara Ackerman Is Both a Nut, and X

pic removed by administrator

How to summarize a complex story? Start from first principles: what does the author want to be true?

Sara Ackerman is a student at NYU, and sent a mass email to the "Department of Social and Cultural Analysis" complaining, inter alia, that a professor forced her to go to OWS and do an ethnography. Her complaint was not that it is impossible for a college student to do an ethnography of a fluid movement comprised of people who in, say, November are completely different than the people there in August, rendering any conclusions not just moot but misleading, or that the term ethnography is correctly spelled "personal anecdote," which would have been my complaint. But then again I didn't go to many of my classes because I thought they were full of people who didn't care or blindly followed the typical herd mentality. Was I right? NB: that's an ethnography.

Her rambling, highly fonted emails are the typographic equivalent of an old time ransom note, and I have every suspicion she's a nut.

Your problem is that the accompanying pic to the NYU article about her is this:

Uh oh. Things about to go racial up in this joint.

II.

Gawker's summary of her complaint:

...objected to being "forced," in her words, to interview "criminals, drug addicts, mentally ill people, and of course, the few competent, mentally stable people"--[Sara] did not like this [assignment].

And the NYU paper continues:

She requested an alternative assignment, but wasn't granted one by CAS Dean Kalb until, she had already gone down to OWS "with two other young girls, who are quite attractive and thin, and don't look particularly physically fit enough to take on a potential predator, rapist, paranoid schizophrenic, etc" and felt like she "escaped an extremely dangerous -- and even, life threatening -- situation."
So it is pretty clear that she sounds like she was afraid to go there.

But then there's the picture. That's a picture symbolizing what she is allegedly afraid of. No picture of her is available, which is weird, as she has 1000 followers on facebook and I found it in 9 seconds (though it took hours to verify), but if you open the Textbook Of Media it becomes immediately understandable: her picture is not useful to their narrative. If this was a story of a sexual indiscretion they would find a pic of her in a bikini, and if she doesn't fit in a bikini they'll use someone else in a bikini as a symbol.

If you take the phrase, "quite attractive and thin", and juxtapose it with the pic above, or the picture NYMag used:

You've set it up nicely: white girl is afraid of black people.

In fact, her actual complaint is that she disagrees with OWS, on principle: "a movement that runs entirely against my core values, and principles". I'm not saying she's not a nut; she may also believe there are drug addicts and rapists down there, she may be afraid of them, but in her brain the secondary problem is the rapists, the primary problem is OWS.

So that's your second clue: an ideological disagreement-- albeit an insane one-- has been reframed into something that seems self-explanatory: this crazy girl who thinks all of OWS are rapists is a racist.

Which isn't entirely wrong:

On a side-note have you ever heard of that mega-university in Cambridge, Mass. called Harvard?
Long story short, they had a few disputes between a tenured professor, and a big man on campus, and look what happened in the end:

They swapped him:

http://en.wikipedia.org/wiki/Lawrence_Summers

For him:

http://en.wikipedia.org/wiki/Cornel_West

And got a PR nightmare---does anyone see the parallels? Or do I have to continue to spell it out for you, as I have been for over 2 months?

Look, neither Summers nor West is perfect, but why don't you do a little research to see who was more deserving of a prominent position at Harvard?

These are the ramblings of a person whose personality is made of paper mache. But listen to the words, the words she felt were important enough to underline: highly qualified X guy was replaced for terribly inadequate Y guy.

You fill in the X and Y.

"Does anyone see the parallels?"

III.

So she's a nut. So what? Why are we reading about this?

Nothing about her story is interesting or unusual. As a psychiatrist in a university hospital, I have seen hundreds of situations just like this. I'm not saying they all actually had psychiatric pathology, I am only saying that somehow or other, referral or kicking and screaming, they have wound up at the door of the university counseling service. Psychiatry is the tool the system uses when it can't shoot you in the head.

And yes, every year five or so nuts send terabytes of emails to everyone.edu and every newspaper within the blast radius about professorial misconduct, conspiracies, mishandlings, promises broken, he said/she said, with multiple quotes from the Student Handbook. (Here's a protip: if you ever refer to the Student Handbook, you should take a semester off or lithium.) You never see these stories in Gawker, let alone the entire emails, and trust me when I tell you they are more interesting. So why this?

She's a nut, but she's a nut in the required direction: this nut hates OWS, which is to say, only a nut would hate OWS. A nut, or someone who doesn't like blacks, or.... Her nuttiness serves a necessary ideological function, which is to set OWS in opposition to her insanity; OWS is magnified as the voice of reason, the voice of sanity. When the media points out the idiocies of Sarah Palin, Bachmann, and Perry, it isn't to discredit them-- a maneuver that overt would be distasteful to intelligent media; Pailinizing them sends a more subtle but powerful message: anyone who agrees with these nuts is a nut. The point is not to doubt them, the point is to doubt yourself, nudging you closer to center (i.e. leftward.) That's how you win an ideological battle.

Thought experiment: you come across a story about an OWS supporter who is also a nut trying to get her professors fired. What network are you watching? So then why are you watching?

IV.

Sara Ackerman threatened to, and then did, the worst thing you can ever do: go to the press.

The press is not your friend, and when you give them your existence they will use you however they need to, and you will have no recourse. If you happen also to be a nut, you're done for.

NYULocal is a student paper, so it's safe to assume they're deeply pro-OWS. That's not necessarily a bad thing, but the point is that they don't see it that way, they see it is pro-truth, or pro-uncovering the lies of Wall Street. Again, fine; but it means that when they use your image for their purposes, like they are using Ackerman's, they think they are doing a good thing. You can't fight against that.

The essence of an ideological battle is not, "I believe this, but you believe that" but rather, "You believe that, but I know the truth." Because of this, not only can you not convince them of their bias, but it is impossible for them to ever be aware of it. It's not bias, it's reality. Hence "basic" and "fundamental" are attached to the very things that other people see as anything but.

At around 4pm MST, I wrote a comment on the NYUlocal page: "Look at the picture they used. THINK!"

Sometime within the next 15 minutes, both my comment and the pics were gone.

You'll either be surprised or not: I knew they were going to do that. Which is why I screencapped the before and after:

before:

after:

The point here is not that I "caught" them, that is not my interest. What's important is that they took it down in response to my comment. What will they tell themselves is the reason they took down the picture? Or used it in the first place?

Was it that I misunderstood the picture, or was it that I did not properly understand the picture?

---

End notes:

1. The scientific problem with ethnographies is that unlike a clinical trial or even a straight census, the "investigator" cannot be separated from the work. It is simply impossible-- looking forward to some angry comments-- to have an "objective" ethnography because the process of the investigation requires the investigator to apply his own biases and defenses to the work. You strive for neutrality, of course, but there is always conscious awareness that you can't reach it. It mitigates this by weaving within it a narrative about the investigator, the investigator becomes explicitly part of the research, so the reader can (conceivably) make some guesses about why this particular investigator saw this particular thing in this particular way.

I tell you this because Sara Ackerman is thus correct in saying she cannot perform this study. Her hatred of OWS, misguided and shallow though it may be, would interfere, and that would inevitably come through in the study. But, and this is an important but, since no one on the planet would have known who Sara Ackerman was, we wouldn't have had that needed information to properly interpret her findings should she have forged ahead. Which means that in refusing to do the research, Sara Ackerman was the only honest ethnologist in the class.

see also: Why does the media ignore Ron Paul? Not because they disagree

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Schizophrenia and Dry Cleaning?

A reader (who wants me to write an article on autism and paternal age-- I swear I'm getting to it) sent me a reference to a 2007 article finding an increased rate of schizophrenia in those born to parents who were dry cleaners (all Jewish, negating a racial association). The authors speculate it's tetrachloroethylene exposure.
There were 4 cases of schizophrenia, out of 144 dry cleaning families. What's interesting is that in 3 of the schizophrenia cases, the father was the dry cleaner.
How does it happen? There are two possibilities: one is that tetrachloroethylene is neurotoxic in developing fetuses, so the dad must have somehow brought it home with him to the pregnant mom. Or, it affects male sperm/ germ cells.
As for Cho, I don't know if his parents were dry cleaners in Korea, or if they started when they all came to the U.S. But something worth investigating.
BTW: not that this would excuse him even if it were true.
To Leslie, the reader: if you want credit, put in a comment and I'll put your contact info up here.)

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===== ====== ===== The Last Psychiatrist: Scientists Find Evidence For The Unconscious

Not exactly, but follow along with me.

14 subjects were shown 3000 pictures, 3 seconds each. Then, they were shown pairs of objects-- one was the previously seen, the other never seen-- and they had to pick out which one they saw. (pdf of article here.)

The pairs were of three types: paired with something completely different; paired with something of the same type; and paired with an altered version of the same picture.

3000 images-- viewed once-- over the course of two to three hours-- and the subjects were able to correctly pick out the previously seen image 87-92% of the time. Absolutely wow.

Granted, this is a paired identification, and not an uncued recall ("list everything you saw.") But what it suggests is that nearly everything you see is in your brain, somehow/where, at least for a while.

If it's in there, then your brain is making associations with it.

If it is making associations, then its presence is affecting the how/when/why of the "recollection" of something else, just as the how/when/why of the recollection of that object is influenced by what came before it.

Example: are you storing it as a picture (the basket of grapes) or as an action ("object tipped over")? If the latter, perhaps it would have been harder to differentiate it from an overturned basket of bananas then an upright basket of grapes. And that is influenced by whether your life is one of grapes or of overturned stuff.

So that random guy in the red shirt you didn't notice from last week when you were eating ice cream is in your brain, and he's being used to make an association to something else. So, for example, Manchurian Candidate style, when you next see a red shirt, you get hungry.

You don't realize the red shirt made you hungry, either. You just feel hungry "for no reason."

Or it could go the other way-- maybe you suddenly like guys in red. Or maybe you hate them. etc.

Perhaps that's why free association seems so powerful. The trick is to bring unconscious associations into consciousness. That way, you get to choose whether or how it affects you.

Everything you experience-- life, books, images, dreams, sounds, and things you did not even notice you experienced-- becomes part of you, and it matters. We make fun of the white kid who is "pretending" to be all gangsta-- "he's a suburban kid from Irvine!"-- but that "fake" experience actually matters. Certainly less than a kid who lead a real gangsta life, but more than someone who never imagined living it.

IAnd it probably extends beyond identity to ability, and it speaks to the power of visualization. Who's more accurate with an M16 rifle: the 19 year old who's watched action movies his whole life, but never touched a gun or rifle; or the 19 year old who's watched no movies and never held a gun?

Everything that happens matters; we just don't know how.

You can't control a red shirted guy passing by you; but you can control, say, what you watch on TV, and how; who you talk to, what you talk about, how you do or do not decide to pay parking tickets.

It's very hard to understand why we think things, why we do things, why we are who we are. Root causes are never fully understood, probably are outright misleading the rest of the time. But what you do have control over, every moment, isn't the why, but the what.

(BTW, if seeing an image in your mind can affect you, imagine what a fake image can do.)

===== ====== ===== The Last Psychiatrist: Second Life Is A Second Chance, Which Is Why It Fails

my avatar

A man makes a documentary about Second Life, the online immersive experience, as a way of commenting on the larger issues of internet addiction and escaping from reality. Is the movie good? No idea. Are you about to be lied to? Oh yes, bring a sandwich.
This is what The New Yorker wrote:

Ingenious... suggests the porous boundaries between the fictive and the concrete, the power of role-playing in defining real identities, and the risky self-discoveries that may result.

Which, like everything else in The New Yorker, means Bush invaded Iraq under false pretenses. And Variety:

A peerless study... every thread here raises a provocative question about the ethics of online interactivity, and serves to demonstrate the Web's ability to both facilitate and destroy human relationships... a chilling window into the psychology of the internet-obsessed.

There is something presumptuous, not to mention deluded, about a print magazine that no one reads claiming that a movie no one will see is a peerless window into something anyone can access anytime they want.

II.
Ponder that flippant run-on sentence for its hidden truth. Who judges whom? What are the criteria for becoming a judge? It's not popularity; nor the sophistication of the staff and writers; or the insight of a director. In the hierarchy of authenticity and truth, which one is at the top? Why can Variety call someone "internet obsessed" but no one can call Variety a "comic book" which, as I am about to show, it is?
There's plenty to be said about the people obsessed with the internet. But Variety cannot-- not will not, but is physically unable-- to discuss it, because-- well, let's not get ahead of ourselves.
This movie doesn't represent a "window into internet addiction." It represents the narrative, the way other people who are not internet addicted are going to think about those who are addicted.
So here's the obvious one, the typical narrative of the "normals": on Second Life she's a Fahrenheit 500, in Real Life she's a fat chick.

Dramatic music, and scene.
The script, the editing, the music, all indicate that this is the message, to "normals": "hey you guys, be careful when you log on to the World Wide Web, people aren't honest." Catfish, another documentary style movie about facebook, was also presented in this way. By normals, for normals.
If you saw Catfish, you cannot help but be struck by the obvious: that normal guy is complete douchebag. But he can define himself as normal in comparison to someone else; and the bigger the scale of this comparison (e.g. a movie) the more true it is. So, phew, he's not a loser for falling in love with a facebook profile, let alone driving to Canada or wherever she lived without telling her first, no, she's a loser for lying to him about her appearance. Oh, that makes sense.

he photoshopped her into his naked pic to show how real he is

But since he made the movie, it's his version that is the default. Yes, you can disagree with him, but the burden's on you. Suck it. So, too, this movie: the message throughout is: "normal people are not like these people."
I accept it's not their responsibility to be fair and objective to Second Lifers. But don't for a second think you're understanding anything about SL users. All you're seeing is the filmmaker's bias in HD: there's real life, and fake life, and these people are pretending to be something they're not. On the internet, no one knows you're a dog.
The thing is, no one on the internet cares if you're a dog, unless they are interested in bringing that world into this one, which they are not. I run a quasi-anonymous blog, and for the most part no one cares who I am because it isn't relevant to their reading of this blog; and my ego isn't wrapped up in having people know it, so we're all cool.   This movie, much less Variety, cannot comprehend this state of affairs at all.

III.

The film shows a man and a woman finally meeting in real life after a long time together on SL. They are almost normal because they want to bring the relationship into the real world.    So the man says to the camera, "it's a relief that when we finally meet, she is who she says she is." What could he mean by that? Of course, duh: she generally resembles her avatar, i.e. she's hot.
I think we've all been on the receiving end of a westbound Aeroflot flight praying Katya looks like her profile pic, so I don't necessarily begrudge this guy his relief that she weighs less than he does. That's not what makes him insane. This is: Second Life is completely fake, yet what attracted him to her in the first place was her sexy avatar. If her avatar was of a fat chick, he never would have connected with her on Second Life.
That's the thinking of someone who isn't "addicted to the internet" who still thinks it somehow reflects reality. Those SL clothes are fake; that SL hair is fake. The way she SL kisses is pure game programming, not some derivative of her emotional experiences. Yet somehow he thinks it's telling him something about the real her. Does he think that's air he's breathing?
People who escape from reality into SL have a set of problems, obvious problems. But the people who want it to mirror this one because this one hasn't given them what they "want" are truly nuts. Why are you reproducing this reality in that one? The black woman above says her in-game job is to create houses. Why? There's no point. Your avatar doesn't sleep, doesn't shower, doesn't anything. I may think it's a waste of time, but the only reasonable thing to do on SL is to walk around and meet other people, create fantastical spaces, experiment. Using Second Life to shop at an American Apparel is like dropping acid in order to defecate.

IV.
Everything wrong with Second Life and other online diversions can be summarized by this picture:

On Second Life, you spend a lot of time looking at yourself.

V.

But give the director his platform, let the subtext become raw text: What the hell is wrong with these people? What could possibly make them want to give up their real lives in favor of nothing?

I wish they had just asked that explicitly, but then the movie would have to be redone with the cameras pointing in the opposite direction.

When your wife withdraws into 8 hr/d of Second Life, are you completely blameless? Is there no human marriage she could have been in that wouldn't have resulted in her making the jump to cyberspace?   Louis CK: "When someone says, 'I'm getting divorced,' don't 'awwwww' them, because it's a good thing. No good marriage in the history of the world has ended in divorce." Or in immersion in Second Life. Or constant facebook. Or porn. Or etc.

Don't confuse longevity with good. A marriage can last forever as long as the two fleshbots don't have to interact long enough to hate each other.

"Our real life partners don't know what we're up to," some man says as his avatar makes out with some other avatar by a pretty lake. "As far as they're concerned, it's just some kind of game that we play."

I don't need 3D glasses to see what's going on in this guy's life. He may be a tool, but that's not why his wife doesn't take the game seriously. His real life wife doesn't take it seriously because she doesn't take her marriage seriously. She doesn't notice he's on the computer all night and distant all day? Or doesn't she mind, because she's too busy with her own self-absorbed lifestyle, her void filled with [insert junk food here]?
Look, if you're going to make a movie about something you should at least make sure someone hasn't already written the book, twice. The conceit of this movie is straight out of Baudrillard, but the director apparently doesn't know it. Second Life is fake, but it's fakeness is overt. While we shoot spitballs at the users of SL like jocks at a 9th grader in a 14ft scarf, the true purpose of SL, for us, for those who don't use it, is to make us think that the real world is, indeed, real. That we're cool. It disguises the fact that the world outside of Second Life is equally fake and manipulated, but in 3D. The real world marriage is fake, the words they say to each other are fake, the politeness is fake, the ideology is fake, and don't get me started on the shoes. Nothing about it is real.
I know, I know, when "Gallifrey84" kisses "ChasteForJondalar", it's just SL's software simulating a real kiss; but back in the 3D world when that guy kisses his wife, that's even more simulated. It isn't even acting, which would at least arouse someone watching it. This "real" kiss is an instinctive, rehearsed simulation of what they saw on TV or used to do in the past. And no one would get turned on watching it. "But at least the lips are touching in real life." So what? Your lips are real, you aren't. So?

VI.
Second Life, as an immersive experience, fails because it isn't immersive, it's only two out of the seven senses (penis and vagina). So it is certainly a poor representation of real life. But FF three or four generations, maybe we get some holodecks or a fully functional Matrix. Now what? Are they running towards something cool or running away from something that's not? You can't get the answer without evaluating the thing behind them.

The reality of it all is simple, which makes it very difficult to fix. These aren't sick individuals, it's a sick society. People are being squeezed like silly putty by the fist of branding. We see the "losers" oozing out of "reality" through the fingers-- some of these losers go to Second life, some to porn; but there's the others who are squeezed more into "reality," into branded clonocity, their existence depends on no one looking at them from the outside and noticing that they aren't actually individuals. "Huh? What does that mean? What? Speak English!"
i.e. for example: most hot chicks, in order to be hot, copy something a celebrity wears; remember the Rachel-do? No problem, they look hot in it; but their delusion is that they are referencing Jennifer Aniston and not the millions of other women with the exact same haircut, i.e. that they draw their identity only from the celebrity's identity-- "This look really says me!" Yet sit along the wall of the bar and the conclusion is inevitable: yes, you're hot, but you don't look like Rachel, you look like the other hot chick right next to you. And, bafflingly, you did it on purpose.
If she looks at you with sudden realization; or if she says, "I know, but I still like it," she is free. If she looks at you like you don't get it, like you're insane, get out, you're in the wrong bar, neither of you will ever be happy.

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===== ====== ===== The Last Psychiatrist: Secretary Paulson Implements the Regulatory Act of 1773

The news is out: US to buy stakes in banks, first since Depression.

An Act For Establishing Certain Regulations For The Better Management Of The Affairs Of The ~~East India Company, As Well In India As In Europe~~ US Banking System

Whereas the several powers and authorities granted by charters ~~to the united company of merchants in England trading to the East Indies~~ to banking companies have been found, by experience, not to have sufficient force and efficacy to prevent various abuses which have prevailed in the government and administration of the affairs of the said united company, as well ~~at home as in India~~ abroad, to the manifest injury of the public credit, and of the commercial interests of the said company; and it is therefore become highly expedient that certain further regulations, better adapted to their present circumstances and condition, should be provided and established: ...
By these acts is established the United States of America Company. We are all mercantilists now. Auspico Presidentis et Senatus Americaniae.

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===== ====== ===== The Last Psychiatrist: Selegiline Again-- Neuroprotective?

As a final point on selegiline, it has long been thought that its efficacy in Parkinson's is due to the inhibition of the metabolism of dopamine. Which is true, but there may be more to it than that.

A summary of this fascinating article:

Apoptosis is different from necrosis in a fundamental way: it is signaled, rather than directly caused. In necrosis, the cell rapidly dies, the plasma membrane ruptures (with resultant irreversible ion shifts), but DNA stays intact. In apoptosis, the plasma membrane stays intact, but the cell shrinks, chromatin condenses and the DNA fragments.
Signaling is important: the genes p53, bad and bax induce apoptosis, while the Bcl family of genes promotes survival. It is now thought that apoptosis mediates substantia nigra neuronal death.
So anything that delays or stops apoptosis could be neuroprotective.
Selegiline seems to be such a drug. Since it inhibits the metabolism of dopamine, it will also prevent the formation of free radicals associated with this metabolism. But, through a mechanism totally independent of MAO-B inhibition, it protects dopamine neurons from MPTP and its metabolite MPP+. (This is a double effect: MAO-B inhibition prevents the metabolism of MPTP to the toxic MPP+; and then selegiline's other unexplained mechanism protects neurons from MPP+.) Its metabolite desmethylselegiline is actually a more potent neuroprotector; and P450 inhibitors which block the metabolism of selegiline to desmethylselegiline, also inhibit the overall neuroprotection.

The anti-apoptotic mechanism of selegiline (and the even more powerful irreversible MAO-B inhibitor rasagiline) is via glyceraldehyde-3-phosphate dehydrogenase (GAPDH). GAPDH is usually in a dimer with a stem-loop of RNA in the cytoplasm. In mitochondrial oxidation, NAD+ levels rise and then knock off the GAPDH, which then floats to the nucleus. There, GAPDH inhibits the formation of of anti-apoptotic molecules, and thus causes apoptosis. Propargylamines insert themselves into the RNA dimer and obstruct GAPDH from dislocating-- thus it cannot go to the nucleus and cause apoptosis.

Additionally, rasagiline upregulates Bcl-2 and Bcl-xl, among other anti-apoptotic molecules.

The study goes on to describe some clincial trials. Indeed, the entire May 2006 supplement in Neurology is about neuroprotection in Parkinson's-- definitely worth the read. We'll have more on this topic after some research.

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===== ====== ===== The Last Psychiatrist: Selegiline: Can I Still Smoke Crack?

Ironically, while selegiline can't be mixed with cheese or Prozac, it can be mixed with methamphetamine and cocaine. A small placebo controlled study found that concomittant administration of methamphetamine (15 or 30mg) with selegiline (oral) caused no EKG, lab, or vital sign changes. The clearance and half-life of methamphetamine was also unchanged. Similarly, 10mg PO can be safely mixed with up to 40mg cocaine, should you be into that. An earlier study found that 10mg/d could reduce the high of cocaine and reduced the activity of the amygdala (as defined as glucose utilization on PET scan) and not caus any negative interactions.
If that's not good enough for you, a study using the selegiline patch 20mg/d in 12 cocaine addicts found that heart rate and blood pressure were lower on selegiline at baseline, and were increased less after 40mg cocaine IV. It caused a slightly less subjective feeling of highness. In case this is not amazing to you, let me point out that as an MAO-B inhibitor, selegiline should increase dopamine levels-- and you should feel more high. But the opposite happened. (Why? Because selegiline already raises dopamine, so the effect of cocaine is less (because there's less dopamine left to increase) and so it feels less fun?)

It had no effect on cocaine pharmcokinetics or dynamics, and did not alter cocaine's effect on prolactin (suppression) or growth hormone (increase.)
A larger, 300 person double blind trial of patch versus placebo (done by the same authors) found no difference for the treatment of cocaine dependence-- but, importantly, there weren't any adverse effects of mixing the two, either.
While not recommended, it appears the patch is at least safe with your addict populations.

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===== ====== ===== The Last Psychiatrist: Self-Embedding Syndrome: What's Going On In Ohio?

A poster presented at the Radiological Society Of North America. Self-embedding syndrome: adolescents embed foreign bodies into their arms, hands, etc. In this x-ray, she's embedded 8 pieces of metal into her arm.

What caught my eye were two things: first, even though this is an old problem, the authors say this is the first study on this, suggesting that it's on the rise (enough for radiologists to notice.) Second, that it happened in Ohio-- which was, along with Indiana, was responsible for half of the youth suicide increase in 2007.

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===== ====== ===== The Last Psychiatrist: Seroquel For Bipolar Maintenance

A brief history of the past decade.

I. Background

A mood stabilizer is a drug that prevents mania and/or depression. Depakote was the default mood stabilizer since 2000. Hundreds of papers promoted its use, though all relied on a single double blind, placebo controlled trial as support for its efficacy. Mentioned almost no where was that this trial did not show any superiority over placebo. However, Depakote enjoyed tremendous sales in the years 2000-2008, showing 10-20% growth per year.

II. But the bulk of the support, especially in journals, came from academics who believed in it, not Pharma?

Since the academics have no relationship with Abbott and are motivated only by clinical efficacy, we can expect their promotion of Depakote to continue even after it goes generic. Oh, wait, that happens in 2008.

III. The Sad, Quiet Story Of The Mainetance Trial That Wasn't

Here's a quick summary of the (only) Depakote vs. placebo for maintenance study: manic patients were enrolled, put on Depakote + any other necessary meds until they were stabilized. Then these patients were randomized to Depakote, lithium or placebo.

At the end of the study, all three groups had similar relapse rates. Putting them on Depakote was not better than placebo for maintenance. On this single, failed trial, an entire decade of psychiatry was premised.

However, there is one technical point that I have never, not once, in 8 years, seen written about, discussed, or even alluded to, and when you do bring it up people look at you blankly: the study patients were stabilized on meds, then randomized to drug or placebo. So those that were randomized to placebo had their stabilizing meds stopped. They were "taken off their meds." So actually, being on Depakote was not simply no better than placebo, it was no better than abruptly going off your meds. Take a long hard look at yourselves.

IV. Two Drugs Are Better Than One

Depakote continued to be grow, continued to be a "mood stabilizer" when it was really simply an acute antimanic. NB: it may be true that Depakote is a tremendous mood stabilizer; you can't condemn the drug on one study. But, importantly, in the decade of "Evidence Based Medicine" why was it at the top of every treatment algorithm and guideline? There's the rub.

But psychiatrists did not use it as a monotherapy mood stabilizer-- it was always "mood stabilizer" plus something else.   In fact, the major discussions in psychiatry 2001-2007 were whether/how additional medications would benefit when used with Depakote. No one asked whether Depakote itself was a mood stabilzier-- that was assumed. The question was whether adding antipsychotics to Depakote provided additional benefit. The answer was always "yes" as long as the question had the caveat, "notwithstanding details or generalizability."

Consider the study of Depakote alone, or Depakote + Risperdal, for the treatment of acute mania. Which is better?

The graph is clear: the combination is better than the single drug alone. BTW, every atypical antipsychotic has a similar study with nearly identical results.

Two sleights of hand:

1. This is a study of acute mania--3 weeks-- not maintenance. The study does not say that Depakote + Risperdal will provide better maintenance control over a year. Yet that is how the results were generalized-- psychiatrists left their patients on "whatever" broke their mania. You can see how, over time, doses and number of meds keep going up.

2. See the y-axis? It doesn't say "amount of improvement," it says "percent of patients." It doesn't say that each person got more better, it says more people responded to two drugs than responded to one drug. We assume the superiority was the result of the combination. But how do you know it wasn't due entirely to the Risperdal? If you give a room full of manics Depakote, 25% get better.    If you give a room full of manics Risperdal, 25% get better. If you gave both to everyone, then 50% would get better, but it's pretty clear that the Depakote responders didn't need Risperdal, and the Risperdal responders didn't need Depakote. Indeed, when you look at change of symptom severity, two meds was no better than more of one med.

This chart could simply be the result blasting patients with two drugs, hoping one works. So this doesn't say "if a drug fails, add a second." It says, "if a drug fails, switch to something else."

Which should have been so obvious as to never have necessitated a study.

V. So Then It's Agreed: Let's Change The Definitions So We Don't Get Caught

At some point, someone is going to notice that polypharmacy isn't working as promised; that it is not particularly safe; and that it certainly isn't worth the price.

And Depakote was going off patent. What to do?

What you do is write a completely unimpressive, pointless article (Effectiveness of Adjunct Antidepressant Treatment for Bipolar Depression) based on a multimillion dollar government finded study that tells us nothing we didn't already know for decades, in the most prestigious medical journal (NEJM) available, and in it sneakily and gigantically change the definitions of words to prepare for the next wave of psychopharmacology, granting plausible deniability.

Mood stabilizers were initially limited to lithium, valproate, the combination of lithium and valproate, or carbamazepine. In 2004, the protocol was amended to define mood stabilizers operationally as any FDA-approved antimanic agent.

Now, in two sentences, all the junk articles that used to apply only to Depakote can now be reused to apply to antipsychotics. "We've known since 2001 that mood stabilizers, for example Depakote or Seroquel or Abilify, are maintenance agents..."

VI. But How Can Antipsychotics Be Mood Stabilizers If They Are For Psychosis?

At first glance, the question seems reasonable, but for the fact that the none of the capitalized words above have any meaning at all, except those with three or less letters.

Seroquel for maintenance bipolar. Why not, a priori? Why would it be any worse than Depakote, a drug which didn't work anyway?

The problem, however, is that by pushing Depakote as a maintenance agent for so long, everything is reflexively considered second line, an add-on.

So because of the artifice, the semiotics, "bipolar requires mood stabilizers; Depakote is a mood stabilizer; bipolar needs Depakote" you can't do a Seroquel monotherapy study. It has to be done as an adjunct to Depakote or lithium.   Therein lies the problem with the interpretation of the results.

The results are, indeed, impressive: people on both Seroquel and Depakote had fewer, and later, relapses than those on Depakote alone. This holds true whether you are looking at relapses into depression, mania, or all mood episodes.

So, for example, by 52 weeks, about 25% of Seroquel + mood stabilizer patients had relapsed, while 62% of mood stabilizer alone patients had relapsed. That's an NNT of roughly 2.5, i.e. you need to put 2.5 people on Seroquel to reliably know one person benefited. Lipitor's NNT for reducing heart attacks is 25.

Although you're not supposed to compare results from different studies, I feel completely comfortable saying that the Depakote curve here is about the same as it was the in other maintenance study, i.e. no better than placebo. (Stop using Depakote.)

VII. But Is It Measuring Prophylaxis Or Relapse?

Look back at the Depakote study for a hint.

Patients were all stabilized on Depakote/Li with Seroquel over 36 weeks, and then randomized to either continuing Depakote/Li + Seroquel, or to being taken off Seroquel and being left on Depakote/Li. Those left on Seroquel did well; those who had the Seroquel removed did not.

So on the one hand, you could say "the combination prevented relapse," or, you could say, "abruptly stopping your Seroquel results in a relapse." Do you see the difference?

With the Depakote study, stopping your Depakote had no adverse effect. For whatever reason, stopping your Seroquel apparently does result in prompt relapse.

You are being tricked (not on purpose) by the presence of the Depakote, thinking that this is providing you some degree of mood stabilization, and the Seroquel is adding to it. Wrong. The Depakote is providing you nothing. The Seroquel is the mood stabilizer. And "stopping your meds" is, after all, not a good idea.

VIII. What Dose?

There is one other important result of this study. The patients were not simply on Seroquel; they were on Seroquel at fluctuating doses, per the judgment of the doctor, 400mg to 800mg. That is key. Seroquel didn't prevent relapse; rather, raising the dose whenever they needed it, and possibly lowering it when they didn't, is what kept them stable. Maybe if they were on a fixed dose of Seroquel the whole time, no opportunity to raise the dose, people would have relapsed more frequently. But this way, at the first sign of trouble, you pre-empt it by increasing the dose.

In other words, Seroquel didn't prevent relapse; prompt intervention by the doctor as things developed (using Seroquel) prevented the relapse. This doesn't diminish the utility of Seroquel, but it also doesn't mean you can put everyone on 600mg and say, "see you in a year."

That is, perhaps, why Depakote failed: it relied on a steady dose, titrated to an imaginarily important blood level that it seems never to have occurred to anyone to ask why we target.

IX. The King Is Dead, Long Live The King

Just as Depakote was an overhyped drug that will thankfully die with its patent, it is more than likely that Seroquel for maintenance bipolar disorder represents some sort of top in the antipsychotic market. It will enjoy massive, and steady, use for several years, but I doubt if there is much growth left in it. Astra Zeneca thinks it has penetrated a market; but it has really opened the doors for all antipsychotics in the same market. You can prescribe Seroquel; don't invest in it.

Simultaneoulsy, just as I was a vocal advocate for the use of antipsychotics over the massive overuse of Depakote-- and I thus contributed to the rise of Seroquel (and others), my new target may be the overuse of antipsychotics.

The target is not Pharma or reps, but academic physicians who are politicians posing as scienticians. Completely absent is the pursuit of science or truth-- e.g, "we didn't expect this result, I guess we were wrong"-- but diversions and sleight of hand. The point is not the results; the point is the discussion. The message doesn't matter, the medium is the message. They have an allegiance to a given concept, and they defend it, promote it. No different than a PAC. And when their King dies, they celebrate as if they never believed in him at all.

But at least the rise of Seroquel will benefit humanity in two important ways. First, it brings evidentiary support to the not common enough practice of fluctuating the doses as needed, up and down, rather than relying on a set dose.

Second, it means the demise of polypharmacy (until they invent a new class of drugs), the drastic reduction of the number of medications patients will be prescribed, especially when coupled with the slow demise of SSRIs.

===== ====== ===== The Last Psychiatrist: Sex In The City 2

dum dum dum-dum, dum dum da-dum

Sex And The City 2 is not the worst movie ever made, because it is not actually a movie, it is a 2.5 hour Bin Laden tape entitled, "Why We Hate You." Fifteen minutes into this recruitment video I hit up twitter:

thelastpsych @alqaeda whats ur paypal? I want in I also have drug pens and wicked sneaks

thelastpsych d alqaeda can u pick me up at the airport? or can meet you at Tony's

thelastpsych d alqaeda on 2nd thought dont bother, in a generation we'll be extinct

alqaeda @thelastpsych @abiliquel @speidi @bananasplits @axlrose @bjclinton @chrisnoth IF THIS IS IN RESPONSE TO THE MOVIE, THANK YOU FOR YOUR INTEREST. WE ARE CURRENTLY EXPERIENCING HIGH CALL VOLUMES. PLEASE TRY AGAIN TOMORROW.

thelastpsych @alqaeda noobs get on teamspeak i'll be on after work

This movie was prohibitively terrible, even though I paid for my ticket, I still had to sneak into the theatre. Think about that.   "I'm really here for the A-Team," I told the usher.   "I bought the wrong ticket for my hot girlfriend, who's at the bar ordering Grasshoppers that are not for me at all."

He took a deep breath and puffed his cheeks out, exhausted. "Keep your hands where we can see 'em, wildman, this is a family joint. And leave the London Fog in the car."

II.

You may be aware that the gals, courtesy of Samantha's recession-proof job as something vague go on an all expenses paid trip to Abu Dhabi, which is also recession proof, even though, of course, it's not. There's no evidence of a recession anywhere in the movie because BORING.

Here's what's weird: the government of Abu Dhabi wouldn't let them film the movie there, so they instead filmed it in Morocco. But they left it as Abu Dhabi in the story. I'm pretty sure the average SATC viewer does not know the difference between Morocco and Abu Ghraib, let alone Abu Dhabi, so why the pretense? I'm not trying to be funny, I'm sure they can see that the letters spell different words, but if I asked anyone in that theatre if Abu Ghraib was the capital of Morocco, you don't think they'd have to call Facebook if it wasn't the other way around?

Samantha: Doesn't Abu mean "penis" in Middle Eastern?
Carrie: I thought it meant "something gay."
Charlotte: I think I may be gay in real life.
Miranda: No, that's me, you're confusing your characters. You're the girl that all straight guys say they'd do if Al Qaeda forced them to choose. The dark haired innocent and naive one.
Bin Laden: You've also aged the best out of all of them. There's probably a moral there, but it got lost in all the crotch shots.

III.

I'm pretty sure Matthew Broderick is not gay, because no woman married to a gay man would appear in a movie where gays are forced to play 8 year old school girls. The movie features a gay wedding that is completely incomprehensible on any level. Right off the bat: the two "brooms" (yeah) have always hated each other, but can still get married because they don't have complicated emotions like 40 year old white women.

Carrie: My life has become much less gay since I got married.
Brooms: If we overlook a decade of animosity and get married, would you come to the wedding to be the center of attention?
Carrie: It would be my pleasure.

And why is Liza Minnelli in the wedding? Why is she singing Beyonce's "All The Single Ladies?" IT'S A GAY WEDDING BETWEEN TWO GAY MEN. Why is Carrie in a man's tux? That doesn't make any sense, they're gay, not transvestites. But for an audience that concedes, "Abu Dhabi/Morocco, what's the diff?" such questions are clearly beyond the point, the point being that the gals lead fun, exciting lives, reality be damned. Walk into any 20 something bar in America and the semi-drunk girls in the corner have at some point played "If we were in Sex and The City, I'd be______" and it never occurs to any of them that that game is the very reason they're on Cymbalta.

The movie isn't just an affront to homosexuals, it's an affront to stereotypes of homosexuals. If you're looking to see a movie where two gay men with infinite leisure time lounge fully dressed on someone else's bed and ooh and ahh while an ex-Chud tries on different unflattering outfits, then I suggest inpatient.

But the wedding isn't for the couple, of course, its sole purpose is to give Carrie the opportunity to reflect on her own married life. She relates every second the wedding to what's going on in her head. Not obtrusively or egotistically, but quietly, with a smile, so you get the false impression she's happy for the couple. Is it impossible for Giappetto's first attempt to engage the world without making it completely about herself?

Maybe the gay wedding was the director's little attempt at progressivism, "we at SATC2 support the right of gays to get married!" but does no one think it a little weird that they support the right to do what Carrie et al obviously think is a bad idea for themselves?

Charlotte: My gay friend is marrying your gay friend!
Carrie: Just when you thought everyone you knew was too old to get married, here come the gays!

That's a real quote. What does that even mean?

IV.

Still, you have to give them credit for taking the movie out of New York. Got to find fresh meat, I guess. I understand that part of the allure of travel is the opportunity to sleep with exotic people native to that land, believe me, I get it. Have you ever slept with a Hungarian in Budapest? A Botswanian in Gaborone? An Egyptian in Alexandria? A Russian in Brighton Beach? A Texan in Houston? I've done all those things and more, and my evaluation of intercontinental travel is HELL YEAH.

But these four don't even notice the Moroccans around them, unless they are waiters. Not because three are married, of course, HA! dummy, that just means you're not allowed to wear a condom. No, they don't notice the natives because for these idiots, the Middle East is nothing but a backdrop, a set, it may as well just be a green screen. What men do catch their eye? An American ex-boyfriend, the Australian Rugby Team, and a Portugese explorer named Rikhart who for the purposes of the movie had to be from Scandinavia/The Netherlands/what's the diff?

V.

There is a positive lesson in Sex And The City 2, and it is this: spending thousands on shoes, beautiful designer clothes and accessories doesn't make you look better, sometimes it merely highlights your comparative ugliness. The juxtaposition is too jarring for an unsuspecting and unmedicated person to handle. Say you're looking at the ground of a busy sidewalk, and you say, "oh, look, those are a pair of really beautiful Christian Louboutin shoes and HOLY JESUS IT'S MR TUMNUS!"

For comparison, take a look at this man:

His tie, shirt, and haircut are each individually of better quality than my eyes, and cost more. But you wouldn't have thought him any more attractive than if he was standing in a bathrobe on top of a toll booth peeing on convertibles as they passed below.   Here he is dressed for a battle of wits:

No difference. Save your money.

"But I'm not dressing this way for men, I'm doing it for myself." Yes. That's the whole problem right there.

VI.

What I was going to do is talk about how SATC appeals to the heteronormative standards applied to American women in much the same way as the the A-Team movie appeals to men. SATC reinforces the role of women as spendthrift, gossipy, superficial, entitled, playful, and non serious. A-Team reinforces the notion that men should be capable, charming, rough and tough, funny, effective, etc.

But then I thought about how the plots of SATC and the A-Team actually converge into the same movie. See, what happens is that the girls go to Abu Dhabi where their wacky vaginas get them into yet another jam with the religious police, so it falls to the A-Team to weld a hat on a duck and bust them out. Murdoch disguised in a burqa hacks a/the computer and they crash their van into the Dome of the Rock to launch their surprise attack. Faceman then sweet talks all the gay arab clerics, B.A. shoots evil mastermind Manolo Blahnik in the foot, the duck recovers the vaginas, and cars flip over and explode but the drivers crawl out. Finally, at the culmination of a daring helicopter dogfight, Hannibal releases the girls from their prison cell in the Nordstrom Rack high atop the Burj Dubai. "I love it when a plan comes together," says Hannibal, and kicks Samatha off the roof. Fin.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Shame

abre los ojos

Shame is a movie that if you haven't seen by now, you won't, but for damn sure don't attempt to watch it on a flight to Chicago. What you've probably heard is that it is a bleak but honest movie about sex addiction and maybe about incest, full of nudity and uncircumcised penis dangling deliciously between some toned Irish Catholic's legs as he urinates. Sound like something you want to see? Hold that thought.

How do you feel after three hours on the Pornotron? You're able to focus on the math homework afterwards, ok, but at the very instant a blast of semen hits you in the neck your first thought is, "Jesus, I need to kill myself."

That thought-- that instant-- is what the sex addict feels all the time. The question is not why does he feel that-- shame is what you're supposed to feel after anything that involves Craigslist. The question is why it doesn't make him stop.

II.

If you want to understand a behavioral disorder, watch the behavior.

One common explanation sex addicts offer is that it is the novelty that they crave, and when enough people with pathology agree on something you can pretty much guarantee that that agreement is part of the pathology, i.e. an unconscious defense. Sorry artists, broken people aren't given greater insight as a consolation prize. The novelty is in fact trivial: yes, different partners, but the same kinds of sex, with the same kinds of people, in the same places, in the same ways, bolstered by the same kinds of porn.   Repetition compulsion masquerading as novelty seeking. "You don't understand," says the analogous alcoholic, "I'm always looking for new drinks."

The important point is that in sex addiction the addict is not satisfied by the sex he just had because he is self-consciously aware that something unidentified is missing, and that lack leaves the orgasmer with an abundance of disgust and shame. Just went from being a made up disease to a typical Friday night. Right ladies?

This is something the movie does depict very accurately: after Brandon has some sex, he then immediately has some other kind of sex. This isn't an overactive sex drive, it is trying to get the sex right.   That's the dialectic. After he has a quickie with a hottie, he goes home and masturbates. He climaxed with her, he was done, but it didn't take. It is easier to get it right with masturbation, not because the hand knows better than the vagina/mouth/butt/breast but because there are always micro-corrections to the fantasy happening in real time-- so the movie you're shooting in your head has a woman fellating a guy, but then she gives a certain look, and then you make her repeat a half-second of that scene using a different look, then you reverse time by two seconds and make her phone her husband; then that disappears and they're outside on the deck, and it's not her but another woman, now it's a whole other scenario with a different cast, and an instant later back to her again; and impossibly seeing the scene from all possible sides, distances, perspectives-- nudging it this way and that to suit that instant's arousal. In effect, you are not watching a movie but improvising from a melody, or, in more psychoanalytic terms, playing with yourself.

III.

There's a possible incest subtext between Brandon and his sister Sissy.

If you can't see it, it's in the back: they're watching cartoons.

But if you are looking for a hard link between incest and his sex addiction you are wasting your time, there's no answer because it isn't the point of the movie.

Take the unexplained backstory as a placeholder: X happened to these characters in the past, and now they're here; where X= incest, child abuse, murder, cannibalism, school shooting, war...

So the movie inadvertently makes an important point about your life: yes, that does sound terrible, but now what?

IV.

I'm going to offer an interpretation. It won't matter whether this interpretation is correct-- none of this actually happened, after all. The point is to ask why no one else thought of this interpretation that, once you read it, will seem to you an obvious one. Here we go.

The key to understanding Brandon's problem is not just to look at the sex he pursues, but also his attempt at having a normal relationship. That's behavior, too, right?

For the first half of the movie he's rubbing his penis against anything sufficiently (com)pliant, and then he's disgusted with his life and decides he needs to become a normal person. This is your American Psycho/Matrix moment: he knows he's whacked, and he knows what normal looks like-- he can fake it-- but he can't feel it inside. What to do? Patrick Bateman created an alternate universe and then gets confused which one is real-- he becomes psychotic. Brandon tries to create a fake world where he acts like a normal person and substitute it for the real one where he is not: This would be The Baudrillard Matrix. This is why he walks around as one who is in a dream.

See that guy? What he's looking at isn't an elevator door or a floor or a wall, he may as well be seeing cascading green characters. Everything he sees is sex. In the staggered brick pattern of the wall he sees a 69; the rounded elevator button reminds him of a clitoris; a footstep behind him is a woman sneaking out of her husband's bed. These are instantaneous and millisecond association flashes that happen all the time.

So with that seeing of a world within a world, Brandon decides to try a normal relationship-- go on a date, connect, love. Of course he runs the date like it's a movie scene, does things he assumes normal people do in normal relationships: he asks out a nice girl named Marianne, takes her out to a nice dinner, orders wine, talk about where she's from, etc.

However-- and this is of such importance that no one else has even dared to mention it-- the woman he chose to go on a date with is black. From his job.

Slow down, multicultural lemmings, this isn't some dumb TV commercial with a blacks/asians/whites all inexplicably smiling about a shared taste in fast food. This guy is a porn addict: all day, every day, constantly, he micro-scrutinizes every aspect of sexuality to find just the thing that will get him off, and he chose to find love with a black woman.

"Well, she seemed nice, so he asked her out."   So run it the other way: Brandon picks up one night stands in bars, ok, but it's not Mos Eisley, those are nice bars, which means the women he meets there are probably nice, ordinary people. People he could fall in love with if he chose to. So Brandon could have attempted a relationship with the hot blonde he picked up in Act I that he instead used for a quickie-- that was a decision he made.

Right?   She looks nice enough. The law does not require <<hot blondes>> to only be used as sex objects, in most states you are still permitted to love them into their old age. And she was already attracted to him and he to her-- 80% of the way there. So?

Nope, he chose a black woman from Brooklyn. Don't you want to know why? Was this someone he's had his eye on for a while? Someone whose personality he knows fits with his? Shared values, common goals, etc, etc? Again, no, he knew nothing about her. He does a cold approach in the break room.

What's interesting for our culture is that in all the discussion about this film and the nuances of sex addiction, no film critic has wondered about the significance of Marianne's race, maybe because they think its normal and probably because they don't want to be thought of as someone who notices race.

So while everyone pats themselves on the back for their non-judgmental acceptance of the nature of Brandon's addiction-- "it's not immorality, it's a disease"-- they overlook what might be of pivotal significance. "You're a racist!" protests the horrifically bad therapist you should throw your shoe at. "There's nothing wrong with interracial dating!"   I happen to agree, but how do you know Brandon does? Why don't you put down your Mont Blanc and yellow legal pad and ask him?

What drives Brandon is his sexual addiction. So why would we assume Matrix Brandon's pursuit of a girlfriend comes from a different power source than his pursuit of other women? Everything he sees is porn: what is the pornographic significance of black women to white men? Did he pick her because he's MORE sexually attracted to black women, or because he was NOT attracted to black women? Because he thought they were "better" than white chicks? Or because he considered them inferior?

Without understanding that-- without understanding what he sees as a "normal" relationship-- without believing that there is critical information in everything other than his sex addiction-- you inevitably make the wrong interpretation about his sex addiction. For example, the date is awkward but she still goes home with him-- and, surprise, he's impotent. Here's where you're supposed to think, "oh, sex addicts have difficulty with intimacy." WRONG. Maybe he didn't try intimacy and fail. Maybe he did everything he could, upfront, to sabotage his chance for a real relationship. He chose her because he "knew" it would fail, and when it wasn't failing he hit the failsafe: impotence.

I don't mean interracial relationships fail in general, I mean that there is a good chance this character would have diminished expectations for the relationship he was attempting relative to other women, which is why he attempted it. Just to be sure, he tells her on the first date he doesn't think there's a point to marriage. Glad we got that out of the way, gives a gal a sense of possibilities.   That's him trying to be normal? No. That's him trying to fail.

Of course this is a movie and of course Brandon didn't pick her, the director picked her. But if you follow this interpretation, then it may be that he picks women he won't get along with to reinforce his belief that he isn't normal-- so that he can just throw himself into his sex addiction. He doesn't want to change.

If this is true, it brings us to a very important conclusion: he was using her.   No, he wasn't going to use her for sex, but he wasn't going to really love her either. He was using her for his identity. Read this again and understand: when he uses the whores and the quickies to get off he feels SHAME, but when he uses a very nice girl with a legitimate interest in him for his pathetic charade at normality, he feels NOTHING for her.   "We're not bad people," his sister Sissy says to him at one point, "we just come from a bad place." God would disagree, but fortunately for you he is dead.

V.

I certainly don't begrudge anyone looking to lay some pipe or a woman looking for a pipelayer, but again, I am neither a film critic nor a therapist, I do not assume normality for you, I let you decide that for yourself. I may secretly believe that harlots and gays go to H-E-double toothpicks, but I do not think harlots and gays can't be happy until then.

However, if you tell me you are unhappy, if you tell me you are all mixed up about the life you are leading, then expect a critique of the life you are leading, not just the pathology you are projecting it all onto. "I'm a sex addict!" says the guy who can't get it up with black chicks.    You picked your life. You may not think you picked it, you may think you were forced into it and inescapably tied to it, but I saw Badlands and I know that every moment is a choice, right up to and including blowing your brains out. So not sleeping with that hill giant is a choice you chose not to make. Saying, "I had no choice," is itself a choice. Your choices may be stupid, but they're still choices. And as all choices in life are ultimately binary, you really have no one else to blame for them but yourself. Flipping a coin should win you happiness 50% of the time. If you're running less than that.................. consider getting a coin. Unless you're one of those double-bind mofos, then the key advice here is to Costanza the situation and do the opposite of every natural impulse you have. NB: same goes for stock trading.

I get that sex addiction looks like fun taken to excess, but a real addict doesn't think any of it is fun, he thinks it's all terrible. So that's where we start: why are you doing terrible things?

"I can't help it, sex is an innate evolutionary drive that I just have set to turbo!" Funny, that. The popular lie nowadays is evolutionary biology, so that a pursuit of beauty is somehow hard wired, evolutionary, but curiously no one can explain why it's hard wired towards 36-24-32 and not the 36-37-38 lassies in the Yoruba tribe. (They like it from behind.) Oh, maybe natural selection is rendering American white humans more sexually perfect, a process accelerated by their below replacement level fertility. Or maybe not. Beauty is a social construction. I'm all in, but it is a construction nevertheless. The reason I think women are hot today is that they are today, not that they are hot. I watch pornos from the seventies and I think to myself, "well, it would be better than bestiality, I guess." Everyone from the cast of Shampoo to the special guest stars on The Love Boat make me want to be a promisekeeper, meanwhile Wilt Chamberlain had sex with 10000 of these gorgons. Get it? It's a calendar problem, not an aesthetics problem. So when you say you're addicted to "sex" or porn, you're actually addicted to the work product of a Madison Avenue brainstorm run by guys whose names are initials. "Quick, call J.T., the rubes'll eat this up!" Still feel ashamed? Yeah, you should. I do.

VI.

The problem with sex addiction, unlike the other addictions, it is always framed as harm to you. No one uses the actual consequences as a reason to stop. Be careful: yes, you get to feel "shame", but the real problem with sex addiction isn't that it destroys your life but that it destroys everyone else's life. No wife has ever questioned her self-worth, let alone killed herself, because she found a vodka bottle in the back of a toilet.   Try and "admit you have a problem"-- this problem-- to your daughter, and see how fast she gets a neck tattoo. And the risk of sex addiction isn't that you contract a disease, the risk is that you spread the disease. How can you stand there and pretend that any of your hundreds of partners are more likely to be infected than you?

Brandon is toxic death, he just cleans up well. Hookers have the savvy to resist him-- after sex, he asks a pro, "can I get you anything? A drink?" and she just smirks and dismisses him. But what defense does Marianne have? Imagine he married Marianne: why did he do this? He wants a normal life with a wife, super, but he's not willing to give up his reckless sexual pursuits. Is that fair? The analogy to Patrick Bateman is worse than you think: Bateman only imagined he was killing people. Brandon simply doesn't care if he's killing anyone.

The incomprehensible thing about Brandon's pathology is that there doesn't need to be anything wrong with him for him to be addicted. He might have a history of childhood abuse, of course, but he may just as well have not.

Brandon has a very specific problem, and it is not sex: freedom.

In order to get sexual satisfaction from anything, that thing has to be unattainable, or at the very least it must come with rules. You can get release and pleasure from the attainable, but not satisfaction. There has to be a limit, a line, which defines a transgression which then allows you to bump up against it-- and be satisfied. In America, almost anything you can imagine is sexually permitted even as limits to "appropriate sexuality" are everywhere. The awareness of the ubiquity of Photoshop on models serves this same frustrating purpose: this super hot woman that I take for granted that I get to see almost naked for no good reason isn't actually her-- the real her is hidden beneath Photoshop. She is still a mystery. So the Photoshop enhancement only temporarily heightens the sexual interest-- which is why it is paired with products to buy now; the real satisfaction has to be attained elsewhere-- the Photoshopped model triggers a desire to look for satisfaction elsewhere-- e.g. the products, alternatively other women, porn, etc. Similarly, while porn actresses are hotter than ever, three hours in all you want is amateurs. Nasty.

Brandon knows he can get any kind of sex any time he wants, so it always fails. Not sometimes. Always. Watch the movie. But he keeps trying, in the same ways, over and over.   He also tries to simulate the perfect sexual experience, copy what looks like works. He walks by a couple having sex in a hotel window, so he then rents a room in that same hotel and has sex with a prostitute in the window in the exact same manner. Does it take? Of course not-- it was too easy. When you sign a contract with narcissism there's a clause you should pay attention to: if it's easy, it doesn't count.

If you are a product of your behavior, start wearing a watch again to discover who you actually are. If the sex addict gets a watch, hell, gets a calendar, what he will discover is that he has practiced no other skill more diligently than pursuing empty sex that he knows is unsatisfying to him. That's what he's spent the most time on, that's what he knows how to do the best. Better than driving, better than speaking, better than Xbox-- he has that mindset down to a reflex. So why would you expect he'd use any other technique for any other life problems that come up? If all you are is an expert hammerer, everything gets hammered.

The solution to your problem-- and of course only 0.3% of you are true sex addicts, so I am now talking to those who feel a little ashamed at how much porn they use or about the ringwraiths they've bedded-- is not to refrain-- you can't resist your desires forever. You must practice a new skill, you must become the kind of person who wouldn't turn to porn when they are: lonely; horny; boredy. If you practice a new skill enough times, it will become ~~second~~ first nature, and you will be a different person. Please note that it is that last part, not the giving up of porn, that makes the change difficult. Giving up porn is easy squeezy. Becoming the kind of person who doesn't need to use porn on Thursdays at 11:30p because that's when you have a few hours free is hard.

I'm supposed to say porn is bad for you and you shouldn't start, but too late. And masturbating without porn is probably good practice for your brain, which is odd to say but in today's world anything that requires more than 15 minutes of focused concentration is technically Olympic training.

But the practical thing people do wrong with porn is put it in the Matrix: pretend to themselves it's bad, pretend it's not something they do, yet spend tons of time on it. So it drags on for hours. Accept it and lock it down to a specific length of time. You won't feel nearly as ashamed.

Wait, were we talking about Brandon not wanting intimacy?

VII.

There is a single remarkable insight in Shame, unfortunately buried in the midst of all the penis and vagina. The movie is called Shame, but there is a crucial instance of guilt: when his sister attempts suicide. (She survives.)

For a man who didn't notice he was dating a black woman, he is remarkably attentive in other ways; he walks onto a subway platform where police have blocked off a scene and magically he knows his sister has slit her wrists back in his apartment.

How did he know? Because he feels guilty, and guilt is omniscient. You know it's guilt because no one else would blame him for what she did, and yet he knows with total certainty that it was his fault, even though it wasn't. Yet he knows it was.

What he is actually feeling guilty about isn't that he wasn't there for his sister-- that's too easy to get out of-- but that his commitment to his own life made him not be there for his sister. Anyone who has ever lost someone to suicide knows this feeling, and everyone else does not. The guilt, re-framed relentlessly, over the rest of your life: if I hadn't been so into my work; if I hadn't been so wrapped up in tennis; if I hadn't been cheating on my wife; if I hadn't been so religious; if I hadn't watched TV every night and instead devoted that time to him; if I X, if I hadn't Y.

The truth is there is no real answer there, because when you hit the bottom of that devotional cycle you wind back up the other way: maybe if I had given him more space, if I had given him more time alone, if I hadn't forced him to spend so much time with the family, if I had worked longer hours to teach him that life is work, or X...

The only thing I've ever found that works, in the absence of a God who can forgive you, is to understand your guilt as not coming from the failing but generated by you as self-punishment, so that you can go on with the rest of your life. Have you suffered enough today? Then go have a Reuben, they're tasty. You've earned it.

The guilt always stays with you. Always. It never goes away. Never. I'm of course not saying you deserve it, but I know it is your inevitable tormentor. So either you reach some kind of stalemate with it or it beats you down. That stalemate is sublimation.

In Brandon's case it is that guilt which motivates him to try and change his life, so when he sees the married woman from Act I again on the subway he doesn't get up to flirt with her. He lets her go, he has decided to be the kind of person who sublimates his sex drive to devote more attention to his whacky sister,. To being a better person.

That's one interpretation, anyway, but I am telling you now, it is the only one that will save you.

---

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===== ====== ===== The Last Psychiatrist: Shame Is The Desired Outcome

do you see?

Part 1 is here.   If you're from Metafilter, you should probably stop reading now. There are a few articles at McSweeney's I'm sure you'd enjoy.

VIII.

If the movie was a straightforward Hollywood docudrama, you'd never hear about it unless you watch the Lifetime Channel . But-- you heard about it. What did you learn from what you heard?

IX.

One of the big deals of this movie is the NC-17 rating, which you might expect for a movie about sex addiction. Except that there is nothing in this movie that would deserve an NC-17. There is way more nudity and sex in The Hangovers and Brandon's date was never shown with jizz in her hair like Cameron Diaz.

Maybe it was the penis. In an early scene, Brandon walks naked to the toilet. We see him from the living room, bathroom door wide open and back/butt to us, and you can see his penis hanging past his testicles as he is peeing. When he is finished peeing, he then closes the door to take a shower. This scene isn't an accident: it took three takes.

First question: why didn't he pee in the shower like everyone else in NY? Maybe because he's not a pig. Ok, second question: why close the door at all? Or, why not close it for both peeing and showering? In my freshman year of college I lived in a house with both XX and XY and everyone urinated with the door closed; but everyone then opened the door during a shower. Freshmen. The exhibitionism was a deliberate boldness, a dare, wrapped in the hope of sexual maturity that pretended to have forgotten to close the door.   By senior year, however, everyone was showering and urinating with the door open because whatever.

So the answer to why Brandon does it that way is: I don't know. But I know why the movie did this: it wanted to show Brandon's penis in a way that doesn't make the censors go bananas. In a movie about sex, even a showering penis would be too sexual. To unsexualize a penis you have to show it peeing, which is why none of my freshman roommates ever let that happen.

So the movie wants us to see the penis (voyeurism=tickets) as a source of envy-- this is a perfect male specimen-- but they want to make sure you don't get too turned on. But there was a big penis showering itself back in Sex And The City II-- Dante, played by that guy on Dancing With The Stars, and that was five years ago, and only rated R. So now the question is, why is Brandon's penis, even peeing, so much worse than Dante's SATC2 rated R penis?

The answer is: you're supposed to want actor Michael Fassbender's penis, but not character Brandon's penis. "This penis is very bad."

X.

Take a look at Brandon. When media wants to depict a sex addict they depict the wealthy, the good looking, the powerful, the well hung. There are plenty of slimy basement dwelling janitor sex addicts out there, but they are represented as sex offenders. There are also plenty of gay sex addicts out there, but they are represented as gay. Both of you are dismissed, the world has no time for your nonsense. The sex addicts we see in movies and on the news are: rock stars, politicians, sports guys, CEOs. If you think about the demo primed to receive this depiction of lothario as sex addict-- women over 35, i.e. the demo for Shame-- sex addiction needs to be seen as terrible because it is terrible for them. It may also be terrible for the sex addict, but fuck you, we have a society to run.

When you see the word "society" look ahead and to the right, psychiatry is in a window with its scope on you. Sex addiction rarely breaks laws so it can't be punished, and there's no God so the immorality of it is debatable, i.e. inconsequential. It must be a disease, that way other people don't want to catch it. All psychiatric treatment of constructed syndromes isn't about cure but about regression to the mean, where mean= cubicle drone. In other words, the point of offering Priapos treatment isn't that the patient gets better-- no one cares about him-- but that everyone else watching understands what he did is deeply whacked, so don't get any ideas.

When a politician is exposed for enjoying the kind of penetration that society's media arm has always promised is available to all-- self-fulfillment, be yourself, she's an adult and can make her own decisions, as long as it doesn't hurt people it's your choice!-- what other prohibition does society have against him? Shame, aka psychiatric illness, that's it. You can't tell him it's "wrong" to do what you've encouraged him and everyone else to do for three decades, which is why stupid people quickly turn to the default: "well, he lied about it under oath!"   Oh, so that's what makes him a sociopath.

And maybe you're a boring non-sex addicted male with a wife, two kids and a longing for a Chevy F10 Blazer so you don't buy this sex addiction gimmick, "come on, that's just an excuse!" and in that complaint you've met them halfway-- the debate is about that guy, is he or isn't he, and not about the existence of sex addiction.   The system is perfectly happy to give Tiger Woods a doctor's note if he's willing to appear on TV saying he has a doctor's note. Saying Tiger isn't a sex addict means that there are sex addicts, and so you should start wondering whether your woman is wondering if you are one. Better erase your cache.

the condom is there to remind you that it's not about poor judgment

When you make behaviors a disease, ===== ====== ===== The Last Psychiatrist: "She Said She Had Breast Cancer-- But She Lied"

if it's in here, it must be about breasts

It's worth reviewing an old story because wrong is forever.

Suzy Bass, a math teacher at a private high school, had breast cancer:

Because Bass had recently moved to Knoxville and was single, two Webb staffers--Julieanne Pope, 43, and Terri Ward, 51--became her part-time caregivers. "I left my cell phone on my nightstand every night in case she needed anything," says Ward, the dean of faculty.... When Bass was too sick to teach, they'd cover her classes. And they kept a steady stream of casseroles and smoothies going to her condo. "We'd visit and she'd be shaking, pale and so sick," says Pope, Webb's technology coordinator. At school Bass would cover her head--bald from chemotherapy--with a knit cap, and limp from the tumor in her foot.

Except she didn't: she made it all up.

Listening to Bass detail the outrageous lengths she went to over the years to fake her symptoms is chilling.... Bass learned to draw convincing-looking radiation dots on her neck with a permanent marker... She would also roll up a bath towel, stretch it between her hands and rub it back and forth against her neck as fast as she could to give herself "radiation burns." She shaved her own head with a razor and made herself throw up from chemotherapy "nausea" in school bathrooms.

She did it for years, at multiple schools, with everyone, including her parents.

Why? Not for the money-- she didn't ask for any disability pay/leave. So?

II.

I wish this was a joke: the article first suggests it's bipolar disorder.

Despite all that effort and time Bass spent learning how to appear sick, she claims that every time she feigned having cancer, she truly believed she was ill. "In my mind, I didn't lie to anybody," she says.

Could someone honestly believe she is dying while actively lying about it? That's part of the puzzle Bass's counseling team is attempting to piece together. "It is certainly possible that given her diagnosis of bipolar disorder, Suzy could have truly believed she had cancer," says Marvin Kalachman [who is treating her.]

Note the construction of his explanation: the "known" quantity is "she has bipolar" and because of that, it is assumed she could believe her lies. But in reality, we don't know she has bipolar and we certainly don't know that she actually believes her lies. We only know that she lied. But he's accepted her story and given her an alibi.

This is the real danger of the overdiagnosis of mental illness: it prevents any further analysis of the symptoms. The debate from this point on will be about whether she has bipolar, not whether her symptoms-- in this case believing her lies-- are real.

I don't have to wait long for an example, here's the next paragraph:

"It's possible for a bipolar patient to experience delusions lasting days or weeks during an episode, Dr. McInnis [professor of psychiatry at the University of Michigan and a leading expert on bipolar disorder] explains. In Bass's case, however, she went to great lengths to fake symptoms--not a hallmark of bipolar delusions, he notes.
He is correcting the diagnosis: bipolar delusions don't look like this. "Delusions," as in "she believes them."

III.

Fortunately, the article abandons bipolar as an explanation (though not as her diagnosis), and instead turns to something that is even more wrong:

Marc Feldman, M.D., a world-renowned psychiatrist, has treated more than 100 women who have faked serious illness... he believes he has her diagnosis: Munchausen syndrome, a psychological disorder in which someone feigns or self-induces illness to get attention and sympathy...these people know that they are lying, but typically don't know why they're compelled to do so.
You'll be tempted to disagree with me: "this sounds exactly like what she has."

And, he says, a diagnosis of bipolar disorder does not rule out Munchausen syndrome. Currently Bass's counselors have not diagnosed her with Munchausen syndrome and say they are primarily focused on treating her bipolar disorder
The problem with the article's and the doctors' assessments is that they are being fooled by the content of her lies and not the form. Because the focus of the article is cancer, because she's faking a medical illness, the explanation must be some other medical (psychiatric) illness.

What everyone does agree on is that this is a woman who will need help for a long, long time.
"I feel sorry that she's sick, but I don't want her to do it to anyone else."
"I just wish we'd found the right doctor for her 15 years ago."
Bass is currently unemployed, a medical recommendation. "... I'm sick and I'm working on it every day," she says.
If she had lied for monetary gain, no one would assume it's a psychiatric condition, but because the gain is non-financial, she must be ill. That's because in America, only crazy people do things for no money.

IV.

The content of her lies suggests Munchausen's; if this was accurate, you'd worry about this:

But if Bass herself can't promise that one of these days she won't suddenly start faking breast cancer, melanoma or some other disease, how do I know she won't? How does anyone?
Because she "fakes medical illness for sympathy" the reflex is to focus on the words "medical illness," but where you should focus is on "for sympathy." Munchausen's doesn't predict what was in retrospect obvious to her students-- she lied about everything.

List of things said by Suzy Bass most of us believed...

Had Breast Cancer...Lie
Worked for NASA...Lie
Played basketball for Florida State...Lie
Got hit by a tornado...twice....Lie
Good friends with Archie Manning...Lie
Had dinner with Vince Young, Mike Vick, and T.O....Lie
Wrote 3 textbooks....Lie
Name is Suzy Bass...Possibly a lie

Oddly, the Glamour article misses a lie that was right in front of them:

In the fall of 2005, the school nominated Bass for the prestigious Disney Teacher of the Year Award. "[Bass] may be the finest teacher/inspiration I have ever been associated with in 32 years of education," Jim Gottwald, the Paulding County principal told the Athens State University newsletter.
The actual quote is "Dr. Bass."

Meanwhile, it lists some lies Bass herself revealed, but doesn't recognize their importance:

She once pretended she had a fiancé who died on 9/11, that she'd played basketball at Florida State University and that she'd starred in the North American tour of Mamma Mia! "What I did was wrong, and I'm willing to stand up and admit that," Bass says, "but it doesn't change that my intent was never to hurt anyone. Never. I'm not that kind of person."

The point here is that the faking of cancer is completely incidental to her life's narrative, what is important is the faking. She faked cancer because, simply, it worked very well. If she could have gotten sympathy and esteem and identity from faking being a basketball pro, then the article would be called "She Said She Played For The Celtics-- But She Lied!" and it would have appeared in Sports Illustrated.

V.

"So you think everyone is a narcissist?" No, but when you see elements of it, you can make some predictions.

Before everyone goes bananas, I am not judging Suzy Bass-- I'm not saying she is a good person or bad person. "Narcissist" isn't synonymous with "jerk"-- I'm using all of these terms to describe what I see, and make predictions about the future in order to help her and others like her.

The worst thing that can happen to a narcissist is a narcissistic injury-- in which their desired, constructed identity is revealed to be invented. In her case, it was literally fake, not just psychologically fake.

What happens in narcissistic injuries? Rage and violence. But, as a woman with limited targets for rage, it gets turned inwards: depression, suicide.

In 1995, when she was found not to have Hodgkin's disease she went into a psych hospital for several weeks. And, eventually, she had to move-- new location, new relationship, maybe even a new "identity"-- but for sure you don't stay put, exposed to everyone.

At her second job in Dallas, GA, where she was found to be faking stage II ductal breast cancer, she was able to get away and find refuge at her parents house-- where her parents still believed she had cancer. Identity intact.

She eventually went to Knoxville, where she got the math teacher job and ultimately was exposed again, this time also to her parents. Now no solace anywhere.

Once she left Knoxville, Bass admitted herself into an Alabama psychiatric ward and she told doctors she no longer wanted to live.

The Munchausen is wrong, not because it's formally wrong but because it is incomplete, in the same way as saying "it's a thirst disorder" when it's diabetes. If people are watching for "medical lies" as a clue to her condition they will inevitably miss the next set of non-medical lies and, importantly, the suicide attempt that is likely to result if those are exposed.

The problem isn't that this is a woman faking medical illnesses. The problem is that this is a ghost, and it's faking an identity. There are a lot of Suzy Basses out there.

---
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===== ====== ===== The Last Psychiatrist: Shhh-- Don't Tell Anyone Cheerios Lowers Cholesterol
FDA criticizes Cheerios maker for health claims.

The primary business of medicine is business.

So I think, come on, eating Cheerios may be healthy for you in that you are not eating a bacon bits donut, but "lowers cholesterol?" Isn't that a bit of a stretch?

At the same time, is this really a good use of the FDA's time? Don't they have Abilify ads to police?

I.

Imagine my surprise: the FDA doesn't dispute that it lowers cholesterol. The claim that Cheerios can cut your cholesterol by 4% in 6 weeks is apparently backed by a real study (cheerios.pdf) in a real journal that is not available anywhere on the Pubmed. Of course. Pubmed's too full of fake studies that are still online.

But you can't accuse Cheerios of being misleading about the extent of the effect: it doesn't say "gigantosaurously," it says "4%," right there on the box. And that's been there for ten years, the FDA just noticed it?

So why now? And if they don't have a problem with saying it lowers cholesterol, then what are they upset about?

II.

If Seroquel says it is good for "bipolar," that's a violation, because it isn't indicated for "bipolar" but only certain phases of bipolar. Lexapro is indicated for Major Depression, but they can't say it's good for post-partum depression, or dysthymia, even if there is good data, because it doesn't have FDA approval. The FDA is very rigid about language. You can only claim to do the thing that the FDA agreed you could do, even if it is established by everyone else that it can do something else. No extrapolations.

Here are the claims that upset the FDA:

Specifically, your Cheerios® product bears the following claims ort [sic] its label:

• "you can Lower Your Cholesterol 4% in 6 weeks" "
• "Did you know that in just 6 weeks Cheerios can reduce bad cholesterol by an average of 4 percent? Cheerios is ... clinically proven to lower cholesterol. A clinical study showed that eating two 1 1/2 cup servings daily of Cheerios cereal reduced bad cholesterol when eaten as part of a diet low in saturated fat and cholesterol."

I've taken the liberty of underlining the words "hypercholesterolemia" and "coronoary heart disease" in the above claims. I did this, because the very next sentence in the warning letter is:

These claims indicate that Cheerios® is intended for use in lowering cholesterol, and therefore in preventing, mitigating, and treating the disease hypercholesterolemia. Additionally, the claims indicate that Cheerios® is intended for use in the treatment, mitigation, and prevention of coronary heart disease through, lowering total and "bad" (LDL) cholesterol.

Got that? The FDA is upset because Cheerios improperly made claims that it never actually made in reality. Consistently, over the past ten years.

III.

If you're confused, this may help:

the label of your Cheerios® cereal claims a degree of risk reduction for coronary heart disease by stating that Cheerios® can lower cholesterol by four percent in six weeks. High blood total and LDL cholesterol levels are a surrogate endpoint for coronary heart disease; therefore, the cholesterol-lowering claims on the Cheerios® label attribute a degree of risk reduction for coronary heart disease because if total and LDL cholesterol levels decline, the risk of coronary heart disease declines as well.

Translation: saying it lowers cholesterol is the same thing as saying it lowers coronoary heart disease, because everyone knows they're the same thing.

First, this isn't even true. I'm not an Atkins nut, but the cholesterol connection is one of correlation, not causality.    Lowering your cholesterol if it is high is a good idea, but we don't know why; and simply lowering it does not equate to awesome reductions in heart disease.    Lipitor is undisputedly good at lowering cholesterol, but only reduces heart attacks from the baseline rate of 8% down to 4%, which may not be worth the price of Lipitor.

Second, Cheerios isn't overreaching-- the FDA is. Since when does the FDA allow conflating endpoints? It doesn't let antidepressants say they reduce the risk of suicide; yet here it puts those words into Cheerios's mouth.

IV.

Still confused?

Based on claims made on your product's label, we have determined that your Cheerios® Toasted Whole Grain Oat Cereal is promoted for conditions that cause it to be a drug

Not that Cheerios is pretending to be a drug, or comparing itself to Lipitor. The very expression of a claim of health makes it a drug.

Again, the FDA does not have any issue with the veracity of the claim; only that by making the accurate claim Cheerios becomes a drug, which it isn't, so it can't make the claim.

There are a quadrillion "chemicals" that make explicit drug-like claims (penis enlargement, calming, cleaning your colon of spackle and paste, etc) that are much more egregious than Cheerios. Compare to the previous FDA warning letter for claims by Tropical Traditions that also "cause it to be a drug:"

"[C]oconut oil is converted by the body into "Monolaurin" a fatty acid with anti-viral properties that might be useful in the treatment of AIDS:"

See the difference? Tropical Traditions is actually saying it is a drug; Cheerios is merely describing what it does, and the FDA conflates that with a completely different clinical outcome.

Next would be saying fish is good for your heart; milk is good for teeth and bones; chicken soup is good for the soul, etc.

If the hypocrisy here is not sufficient, I'll give you this: if the FDA agrees with the claims, but says the claims make Cheerios a drug, then why wouldn't they mandate that Cheerios get approval as a drug? Instead, they prefer that people keep eating Cheerios but be unaware that it is a drug. Now: ponder all the "supplements" out there. The FDA knows; it doesn't care. It has Abilify ads to police. Do you know why? Because Abilify has a lot of money to pay in fines.

All agencies, private or public, have survival as the primary outcome. No agency exists to close itself.

Don't believe it?

Yes, that's the same Minneapolis FDA that sent the Cheerios warning letter.

The [FDA] has nearly doubled the number of inspectors in its Minneapolis office over the past year, marking a rebuilding of its local presence.

...The "surge" in FDA operations doesn't mean, however, that the agency is gearing up for a crackdown on local businesses, said Charles Becoat, director of the regional office, at the meeting in February. "We're not the big bad police," he said.

So what was the hiring for, then?

FDA's Minneapolis office has also had a reputation of being "rational and sensible," he said.
He's got a point; this is an entirely rational approach to transferring wealth from one party to another.

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===== ====== ===== The Last Psychiatrist: There's A Shortage of Psychiatrists Somewhere, We Just Have To Find It

I was emailed a link to a 2003 article in the Psychiatric Times, which describes a maddening report out of California is so blatantly politicized that Arnold himself is embarrassed.

The report says, insanely, that there are not, and will not be in the future, enough psychiatrists to meet the needs of California. (Actual report PDF here.)

Well, not exactly true, is it?
When you say shortage, what do you mean-- 5000 psychiatrists for one state isn't enough? Oh, you mean that for some inexplicable reason, 63% of the entire state of California's psychiatrists work in the Bay Area or LA? Sounds like you have plenty of shrinks, they're just not distributed very evenly. Why would that be?

48% of all psychiatrists in California are in a solo or 2 physician practice. Hmm. 75% were male, 65% white. Hmm. Perhaps the problem is that your solo psychiatrists want to work in a nice area with good pay, and not in an inner city where-- ironically or tragically, your choice-- the need is greatest but the pay is least?

The nuts filing the report continue to lament that there aren't enough child and geriatric psychiatrists. Enough for what? Oh-- enough for Medicaid and Medicare. What did you expect? After suffering through a Child psych fellowship, why would go work for peanuts in a community mental health clinic, where you have a better chance of getting stabbed than getting rich?

Their complaints are misplaced and deluded. They do not reflect reality. Let me give you reality: the shortage exists in community (read: Medicaid) mental health, primarily because the pay sucks. But even there, the problem is not as dire as they make it sound.

First, even if there are numerically more psychiatrists seeing private patients, the community mental health psychiatrists see many, many more patients in a day. I'm going to guess the ratio is five to one. (Oh, you're upset they see them in ten minute intervals? When you give them a case load of 3000, what did you expect them to do? Psychoanalysis?)

Second, psychiatrists aren't the only ones providing "community mental health." Advance practice nurses (APN) and nurse practitioners (NP) also prescribe medications; in some states physician assistants can prescibe; and very soon psychologists will be able to prescribe, as they already can in New Mexico (and I think Louisiana.). (Care to retract your asinine prophecy, "the center predicts that there may actually be too many psychologists in the future.")

Third, primary care docs handle far more psychiatry than we can imagine. They just can't bill for it. (And so how good a job are they incentivized to do?)

The shortage is for "psychiatrists" proper (i.e. MD/DOs), not "providers of psychiatric medications."
The question then, uniquely, is whether we need psychiatrists proper at all to do community mental health. Are community mental health psychiatrists, as a group, better at diagnosing and treating than anyone else, for example an NP? Sadly, the answer is currently undeniably no. No one reads anymore, no one studies, and worse, the half-learned information that still lingers is so incomplete as to be misleading. Post residency, we get our info exclusively from drug reps and throwaway journals. Ergo, most residents are better psychiatrists than someone in practice ten years.
Woah-- be careful. Think long and hard before you hurl "clinical experience is more important" at me. Make sure you want to go down this road.
I am certain that I can take anyone with a college degree in any science, and in four months make them better than an above average psychiatrist. This is an open challenge to the APA. I'll repeat it: I'll take any person with a B.S. and in four months make them an academic psychiatrist.
But back to our "shortage" problem, or more accurately our distribution problem. The solution to this is elementary, but bitter.   Either raise the standards necessary to be a practicing psychiatrist-- more audits and tests, greater documentation in notes, recertification exams with consequences to failing, and outcome/performance evaluations graded against other psychiatrists-- but also raise the pay, dramatically-- you can use the prescription drug savings when you implement my other plan-- so as not to lose the smart people to internal med or neurology; or lower the requirements so that more people can be prescribers, and lower the pay so that you can afford more of them. Either of these two will satisfy the growing "need." Which is better for the patient is up to California to figure out.

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===== ====== ===== The Last Psychiatrist: Short Film: Bad At Math

I wrote a short story called Bad At Math, about me vs. gun vs. Xanax, and Henrique Cartaxo asked if he could use the idea for a short film.

Some differences: my bad guy was taller, the room was smaller, and my drink was WAY bigger.

Also, a follow up.

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===== ====== ===== The Last Psychiatrist: Should Hubris Be In The DSM-V?

Certain psychiatrists carry considerable weight in determining the policy, the spirit, of psychiatry. Henry Nasrallah is one of those men, which is why, if you see him write an editorial called, "Should psychiatry list hubris in the DSM-V?" -- especially if it is tongue-in-cheek--- you should strike yourself in the head with a brick until you are unconscious. You are about to be manipulated with words, and then it will be too late.

He begins:

A recent book contends that psychiatry has transformed normal sadness and sorrow into a depressive disorder,(1) which would be akin to saying primary care physicians diagnose every mild cough as pneumonia. The book's premise is not true, of course, but it's a perfect example of how misunderstood serious mental illness is.

As a rhetorical point, you'll observe that his opening volley is not to refute the book, but to dismiss the book, ipse dixit. "...not true, of course." The authors of said book aren't some nut bloggers, and despite the premise, the book contains a forward by Robert Spitzer-- the creator of the DSM. Perhaps "of course" is too hasty?

But dismissiveness isn't his real problem, it's his choice of analogies. Psychiatry isn't being accused of taking ordinary symptoms of cough and exaggerating them into pneumonia-- because then it could be easily unmasked.   What psychiatry does is to call "cough" itself a major disorder. It makes this definitional, safely axiomatic, and thus irrefutable. Not, "he's much sicker than he seems," but "what he is, is sick."

Here's another rhetorical trick he uses. He gives examples of what pathologizing human traits would look like to show how preposterous such a thing would actually be:

How about "Verbal Diarrhea" for folks who chatter incessantly at a cocktail party or committee meeting, or "Intellectual Constipation" for our friends with exasperating narrow-mindedness. And for the painfully irritating person, "Social Hemorrhoid" might be apropos.
But this isn't jest, it's Greek Math. He cites these examples so that other things don't seem so preposterous. "It's obviously wrong to eat babies, but under certain circumstances, adults are ok." So while we're crapping on Verbal Diarrhea as a disorder, Internet Addiction slips in unnoticed.

But hold on: the examples aren't preposterous, they are already pathologies. Ok, they're not disorders, but they are signs of disorders. Don't be fooled by the aliases. What Nasrallah doesn't realize (?) is that these "symptoms" signify, connote, a disorder, a process that cannot be undone. "He has mood swings" means he has bipolar, even if he doesn't. Even if 100 psychiatrists later agree he doesn't have bipolar, the diagnosis stays open: every aspect of his life will be forever measured against bipolar.

If the cough is a symptom of "Cough Disorder"-- who can protest?

Let's not forget those who throw temper tantrums when they can't have their way: they may suffer from "Temperamental [sic] [sic] Arrhythmia."
Note my double [sic], his example is wrong all over the place. If it's temper tantrums he's worried about, then the disorder is more properly "Temper Arrhythmia," which already exists: we call it Oppositional Defiant Disorder.

But if he meant a disorder of temperament-- which everyone pronounces "temperment" and so could be confused with meaning "temper"-- then that's a disorder, too, because temperament means innate personality traits: he's having temper tantrums because he is genetically predisposed to having them.

One thing psychiatrists love to do, myself included, is comment on social policy. He couldn't leave this one alone:

Take the worldwide financial meltdown triggered by questionable practices of banking executives who thought they would never fail or be caught on their way to accumulating obscene wealth. They certainly left a lot of wreckage in their wake, so perhaps psychiatry should create new diagnostic entities of "Horrendous Hubris" and "Gargantuan Greed."
He doesn't cite the greed of a generation of people who overleveraged, who didn't save for their own retirement or their kid's college or anything else-- I'm not talking about the poor, I'm talking about everyone who made TVs, DVDs, cars, boots that cost $200 but show up on the credit card statement as "$15/month"--made it so that stuff isn't considered luxury items.

No, he chooses the greedy bankers. On the surface, it seems he's using this as an example of something psychiatry could easily pathologize, but doesn't-- ergo psychiatry is rigorous. But that's all a ruse. He picks this as an example of hubris not being a disorder so that he can label the bankers as greedy. That's the purpose of this example. Someone else's greed-- say, a gambler's, or someone who does not offend him-- that could be pathology, that could be bipolar. So what he's showing you here is not the framework of normal vs. pathology, but how he gets to choose what to pathologize, and when.

My point is that the social retina of psychiatry does not perceive ordinary human traits and emotions such as normal sadness as pathologic behavior. But psychiatrists certainly are willing to intervene when people seek help on their own for problems such as depressive episodes that are disrupting their lives or are referred by physicians or brought in by family or friends who recognize the potential gravity of their afflictions.
Words are always and forever beautiful lies, the enemies of logic, when you hear them you should run away, seal your ears with wax or drown them out with a lyre's song, lest you be seduced to your death; they don't tempt your body, they tempt your spirit, and no one can resist them.

On the one hand psychiatry doesn't see normal sadness as pathology; on the other hand, psychiatry will intervene when someone else sees pathology. So when, ultimately, does normal sadness constitute a disorder? When someone says it does, that's when. Ipse dixit.

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===== ====== ===== The Last Psychiatrist: Should Kids Go To College Early?
Oh my God, does no one see this for the scam that it is?

The worst idea in the history of education, other than making "Health" a requirement:

New Hampshire announces plans for a set of state board exams for 10th graders-- think the French Bacc-- which would allow those who want to to graduate high school two years early and go on to technical, community or regular college.

Those who want to may still follow a traditional 12th grade curriculum, and then go onto college.

Right now, Tucker argues, most American teenagers slide through high school, viewing it as a mandatory pit stop to hang out and socialize. Of those who do go to college, half attend community college. So Tucker's thinking is why not let them get started earlier?
1. New Hampshire is too far for me to go and start punching people.

2. Let me understand: high school is mostly pointless, so the solution you've come up with is not to improve it, but to graduate them faster.

If you think there's an education gap between rich and poor kids now, wait until this passes. You think rich kids will-- will be allowed to-- do this? This is for poor kids, bored, disinterested and looking to get out, and it legitimizes it, depriving them of two years of high school.

3. This is Bizarro Robin Hood, this is a massive transfer of wealth from individuals to the state. Think about the type of kid who would leave high school after 10th grade and aactually go on to college. Is he going to Harvard? No, he's going to a state school. Do you think an at-best average student, with two years less high school, is going to finish college in four? So here we have a system where a kid is going to leave a free school to go to a college he has to pay for, for longer. The state saves two years on high school-- $60 billion, nationally-- and gets an extra year out of the college tuition.

I don't need to point out that tuition is going up, faster than the inflation rate? Especially at state schools?

These people don't care about students, they care about themselves. That's why they want to remove teacher accountability. Why, in bold red 20pt font in the sidebar of the report is the description of how, with all the money they'll save, they can pay teachers up to $110k a year.

4. Don't tell me it will reduce dropout rates-- that's a scam, too. They've simply been graduated.

5. Reducing the number of years in school is actually a great idea, but you're reducing the wrong years. If they really wanted to help "Improve The Skills Of The American Workforce"-- see? that's what they think of you, what they think high school education is for-- then they should try to find a way to make high school so good that you need less college. But where's the money in that?

A real solution would be to cut college down to 2 years. Or even zero: straight to professional school or work. College is reducing our country's productivity and infantilizing young adults. Hi. Is this thing on?

----

The Graying of Kindergarten series
The Dumbest Generation Is Only The Second Dumbest Generation

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===== ====== ===== The Last Psychiatrist: Should School Start Later?

so let me get this straight: you want me to start eating worms

In Harvard Business Review, Christoph Randler explains his research: a survey of 367 college students on their proactivity. Hint: the title is, "Proactive people are early risers."

The finding is not simply that they wake themselves and get going; there's a biological involvement. Early risers were those who got up at the same time on the weekends as on the weekdays, i.e that was what was natural.    Actual amount of sleep didn't matter here.

Other traits, like conscientiousness, were also associated with early rising. The hook in his research is that early risers don't simply have more time to do work, are not better rested or, drink less alcohol. Being an early riser is something innate-- he estimates 50% of it is due to genetics.

II.

There is a point-- and I've seen it frequently-- where late night and early morning converge.

It is my observation, N=1, that I feel more rested if I can get up an hour later than normal than if I actually got more total sleep.

III.

CHICAGO - Giving teens 30 extra minutes to start their school day leads to more alertness in class, better moods, less tardiness, and even healthier breakfasts, a small study found.
"The results were stunning. There's no other word to use"

Could this be about morning kids vs. night owls?

From the abstract:

Conclusions A modest delay in school start time was associatedwith significant improvements in measures of adolescent alertness,mood, and health.

If you were told that school or work would from now on be an hour later, what would you do? What I'd do is stay up an extra hour (or four) so that total sleep time was the same, just shifted.

The teens didn't do that.

Results After the start time delay, mean school nightsleep duration increased by 45 minutes, and average bedtimeadvanced by 18 minutes

Why didn't they stay up later? Because these were boarding school kids, and lights out was lights out.

So their improved mood and behavior may be simply due to more sleep, not a later time, per se.

IV.

See that "advanced 18 minutes"? I blew past it without appreciating its technical significance:

When school start time was moved a half hour later (S2), these idiots didn't stay up longer, they actually went to bed earlier.

V.

So the study shows, basically, that kids do better with more sleep, and if you start school later, they get more sleep.

This doesn't lend anything to Randler's thesis, because when you sleep-- his biological predilection to mornings or evenings-- wasn't really tested. It was just less vs. more.

The reasons we run the world as morning people are myriad. I'm sure it started with the stupid sun; older people naturally get up later, and older people set the meetings. All night owls are expected to adjust their natures.

The effects of this on kids, especially pubescent through mid twenties, ages when the sleep cycle naturally favors later mornings, are not obvious. But they're pretty suspect. Jocks are supposed to be dumb but how smart can you be if you were up at 5am running laps? But that's the system we have. I've rarely met an ADHD kid who sleeps enough, and I've never met an ADHD adult or adolescent who does. When a kid is sleep deprived, he gets hyper; they are too tired to be inhibited, too tired to exert self-control. Not for nothing, Ritalin is a stimulant.

Which is why, for me, the real message of the study should have been this:

The daily class schedule is from 8 AM to 3 PM, 4 days per week;8 AM to 1 PM on Wednesday; and 8 to 11 AM on Saturday. FromJanuary 6 to March 6, 2009, the school start time was delayedto 8:30 AM. To avoid extending the length of the school day,academic and nonacademic periods (student life, music programs,etc), assemblies, and afternoon activities (ie, athletics, theater,etc) were reduced by 5 to 10 minutes.
That's how you run a school.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Shouting vs. Spanking

Fake, fake, everything you do is fake, fake, fake...

From the NYT:

"I've worked with thousands of parents and I can tell you, without question, that screaming is the new spanking... As parents understand that it's not socially acceptable to spank children, they are at a loss for what they can do. They resort to reminding, nagging, timeout, counting 1-2-3 and quickly realize that those strategies don't work... they feel frustrated and angry and raise their voice. They feel guilty afterward, and the whole cycle begins again."

The article describes parents who (of course) wouldn't spank their kids, who thus end up yelling.

Psychologists and psychiatrists generally say yelling should be avoided. It's at best ineffective (the more you do it the more the child tunes it out) and at worse damaging to a child's sense of well-being and self-esteem.
This is absolutely TERRIBLE advice.

II.

The problem is neither the yelling nor the spanking, the problem is when. When these parents yell or spank, it isn't in response to intrinsically bad behavior, it is in response to behavior that burdens the parent.

Note what it is that causes them to yell:

She can emulate one of those pitch-perfect calm maternal tones to warn, "You're making bad choices" ... That is 90 percent of the time. Then there is the other 10 percent, when, she admits, "I have become totally frustrated and lost control of myself."
It can happen... at the end of a long day at home -- just as adult peace is within her grasp -- when the 7- or 9-year-old won't go to sleep.
or

"I'd like to think that most of the time we have a good interaction based on reason," Lena Merrill said of her 4-year-old daughter, whom she has never spanked. But then there are the times when "she's done something like poured milk on the floor or ripped a page out of a book," Ms. Merrill said. "I just lose it."
The yelling isn't just disproportionate to the behavior, it has nothing to do with the behavior. She's angry about other things, but she's yelling about the milk.

The kid has learned nothing about good and bad behavior. In fact, they've learned that "bad behaviors" merit only calm discussion, while things that annoy Mom or Dad are met with wrath.

Watch your kid: are they more terrified of your reaction when they are caught in a lie, or when they accidentally knock over a glass?

The natural thing to do would be to yell about bad behavior ("did you push that boy on the playground?!?!") and be calmly annoyed when they spill milk. But.

III.

But that doesn't happen, because the parent isn't being honest.

I recognize it's done with good intentions, but pretending to be calm and reasonable "as much as possible" is neither honest to yourself, nor helpful to them: no one else on the planet is going to treat your kid that way.

Two-thirds of respondents named yelling -- not working or spanking or missing a school event -- as their biggest guilt inducer.

Read the article: the parents' reactions are all of guilt. But it isn't guilt, exactly--

"Admitting I'm a mom that screams, shouts and loses it in front her kids feels like I'm revealing a dark family secret."
--it's shame. Their yelling reveals them. Their carefully maintained identity (of sensible uber- parent) is revealed as a facade. And the facade isn't in service of the kid

...as parents understand that it's not socially acceptable to spank children, they are at a loss for what they can do.
but in service of their identity of "good parent." But they get exposed, turns out they aren't as rational as they thought-- they yell over spilled milk.

IV.

Consider a mom and a kid in a toy store. The kids starts whining about buying something. He gets loud. The mom hisses through clenched teeth, "wait till I get you home."

I understand she's frustrated. But why is she whispering it? At home she would have yelled, why not just yell now? She's willing to carry the anger by car to another location-- is the behavior that serious?

She's whispering because she's embarrassed, not at the kid's behavior but about what it says about her as a parent to onlookers. And she's even more embarrassed by her reaction. She can't let other people see her rage when it appears to other people that it is only about a kid wanting a toy.

But if she catches the kid stealing, then she'll let him have it, right there in public, because then there's no shame in her yelling-- it reflects well on her.

The yelling isn't the problem, the problem is that yelling is used for the wrong things.

V.

The single problem of modern parents, mothers and fathers alike, is that they are trying to be something-- "good parents" (an identity construct) and not doing what is good for the kid only for the sake of the kid. (I look forward to your emails.) They may be doing good for the kid, but they are also trying to reflect themselves as good parents, they are also considering their shame. That cannot work, ever. The kid will sense this, and the lesson they will learn is that there is no absolute right and wrong, only pleasing the boss.

I'm not judging you, untoggle the caps lock, I am trying to help you understand where it all goes wrong.

If the parents had simply been real-- angry when something angers them, more angry when it is worse and less angry when it is not as bad--they'd feel better, and their kids would learn much better life lessons. If they showed frustration when they were frustrated (and labeled it: "this is frustrating me!") and disappointment other times and rage for the big things-- instead of holding it in and then unloading-- they'd be much less stressed and the kid could learn to mirror a range of emotions, instead of acting out. "He bites for no reason!" There's a reason.

But I have asked a generation of parents raised by amazingly bad parents in 30+ years of a preposterously self-absorbed media environment to forget everything life taught them and be real.

-----

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Six Quick Changes That Will Lead To Better or More Cost Effective Hospital Care

It took me longer to write this then it will to implement the changes.

Consolidate the chart

A patient's medical chart is literally a big notebook. But it's not diary format-- doctors, nurses, and other staff do not write their notes in the same places in a chart. They're in separate sections of the chart. Yes. Just like sixth grade.

It's hard enough to motivate doctors to read through the nurses' notes written right there on the same page; if it's in a separate tab, forget it.

One of the biggest factors in hospital malpractice cases is discrepancies between what the nurse wrote and what the doctor wrote. The nurse wrote "patient agitated" and the doctor wrote "patient euthymic." Maybe the nurse was wrong--a single line from the doctor might suffice ("nurse noted agitation, but this has resolved.")

But if the doctor doesn't see it--and why would he, it's in a whole other tab!-- he can't address it. And then you have two witnesses, one of whom is unreliable but-- which one?-- saying two disparate things. Good luck with that.

We should go back to diary format, including consultations and labs.

Doctors must re-write the prns given in their note.

As above, the nurse will document the administration of, say, Ativan, in the nurse's note, which is in a separate section the doctor doesn't read. But: it is common practice for nurses to chart the medications in an entirely separate notebook. Many doctors are not aware of this, so don't know to look for it. Even worse than that: upon discharge, this medication administration record is inserted into the real chart (notebook)--so for future lawyers, it looks like the information was there all along.

I have seen countless cases where patients were getting an extra 9-15mg of insulin a day from a sliding scale, only to be discharged back on their old regimen-- if any insulin at all. The doctors thought the standing regimen was enough. Nurses appropriately administer and chart the doses-- but this is done somewhere else. Similarly, extra Haldol or Ativan doses are being given by nurses prn, charted appropriately, but the doctor doesn't know it. He has a sense of it--perhaps in rounds he was told it was given--but it isn't real. So when he discharges an improved patient on 15mg Zyprexa, when it really was 15mg Zyprexa + 10mg Haldol that got the patient better.

There is only one solution: doctors must rewrite the prns in their own note-- literally copy them down the way they copy lab values off the computer into their note. It proves they know, and forces them to account for it, it makes it real. No, this isn't a suggestion: it has to be a mandated policy, or it will never happen.

Medication templates

Medications and dosages are always at the discretion of the doctor, but many doctors prescribe according to habit or expediency.

You have to make it convenient for doctors to do the right thing, or slightly inconvenient to do the wrong thing.

Are doctors using too much cogentin (2-4mg/d) with their Haldol orders? Make a template that says "cogentin 0.5mg/d prn EPS." Too much Ambien, not enough Restoril? Make a template that has Restoril as the prn sleeping med.

Too many branded SSRIs over generics? Make a template with all the generics but none of the branded, e.g.

Celexa 10mg/d
Prozac 10mg/d
Zoloft 25mg/d
Paxil 10mg/d
Wellbutrin SR 100mg/d

But no Lexapro or Effexor. Note that in the above example, I have used the branded name for the existent generic medications--you check off Paxil, the patient will get paroxetine. Psychology!

Some medications need special administration instructions that may not be... appreciated by the doctor. For example, Geodon 40mg BID is not going to work; Geodon loses as much as 40% of its absorption in the absence of fat, and BID means 8am and 10pm. The order should be preprinted: Geodon ___ mg with breakfast    ___mg with dinner.

It goes without saying, the doctor can write-in any medication he wants.

Other physicians vs. you:

A chart showing your habits vs. the community is very powerful. Are you the biggest Klonopin prescriber in the city? Most branded meds? More Seroquel 25mg than anyone else?

Average length of stay by diagnosis? Number of medications upon discharge? Number of restraints, etc?

Privacy need not be a concern. The data already exists. Each doctor can receive an automated printout of the data monthly. There is no punishment assigned to it, but each doctor's superego will push practice a little more to the rigorous.

If a psychiatrist wants to admit a patient to the hospital, he must do the precert himself.

Wow. This one is beyond obvious.

Ordinarily, if a patient goes into an ER, and the psychiatrist determines the patient needs to be admitted to a psychiatric ward, he will tell the nurse or social worker his decision--and then go get lunch. The social worker will call the insurance company to "precert"-- i.e. get insurance approval for the hospitalization.

Accept that at any given moment, at least 30% of the inpatients do not need to be there--they could be more cost effectively managed elsewhere, or treatment is more appropriate elsewhere. (Yes, being in the hospital can sometimes be harmful in the long run.) This is even more true if the ward is a "dual diagnosis" unit, i.e. psychiatric disorders with addiction issues. If a Medicaid hospitalization is $600/d, a perfectly legitimate question is if he is better served in a 5 day hospitalization, or in a rehab with a check for $2000 to pay his rent?

It is extremely common that people fake suicidality to get into the hospital-- maybe they're homeless, maybe they're in drug withdrawal and want to get detoxed, maybe their girlfriend kicked them out, etc.

The problem is that even when the doctor strongly suspects the guy is lying, he'll admit him anyway-- it is the path of least resistance. The only "work" the doctor has to do is decide to admit; the social worker has to do the rest.

If the doctor had to do it, it would be a disincentive to admit someone he did not believe needed to be admitted.

But hold on: I don't mean the resident should do this-- I mean the attending should have to do it. Otherwise, it's no different than having a social worker do it, the attending has no disincentive to choose the path of least resistance.

Similarly, once the patient is admitted, the inpatient doctor should have to do a review with the insurance every X days--not the social worker, as it is done now. That single phone call is a powerful disincentive to keep people too long in the hospital.

Perhaps you are worried they will be discharged too quickly: don't. Most doctors are reasonably prudent in their discharges--they err on the side of too long, not too short. And don't forget: as much as doctors may hate insurance reviews, they hate depositions way more.

I'll tell you this up front: many doctors will riot. Those are exactly the doctors you need to fire. They don't get it, they don't want to even consider trying to get it, they do not see that medicine is a system, they still think it is a solo career of infinite resources. "You expect us to do this, on top of everything else?" There isn't anything else. That's the point. It's all one thing, not several different things.

Ban smoking, or make it completely unrestricted

Most inpatient units allow 2 or 3 scheduled smoke breaks. Here's the problem: the metabolism of Haldol and Zyprexa, among other medications, is vastly accelerated by smoking.    A pack a day cuts the dose in half. So it looks like the guy was stable on 10mg Zyperxa on his last hospital day; then he goes back to outpatient regimen of 1-2 packs of Lucky Strikes per day and that 10mg is now 5mg. Wicked.

So either you get them to quit in the hospital, or you acknowledge reality and dose to reality.

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===== ====== ===== The Last Psychiatrist: Sleep Loss And Moral Judgment

There's an article making the rounds that I'd like to kill off right now, before it becomes a meme, or worse, another unsupported postulate common among psychiatrists.
The title of the Reuters news story about the article (in Sleep) is this: "Sleepless nights may hinder moral judgments." And has sentences like this: "[subjects] took a longer time to mull over the morally charged questions when they were sleep-deprived than when they were well rested. This was not the case with the more minor, non-moral scenarios."
And there's your self-serving, exculpatory imbecility of the day: a sleepless night or two turns us into lycanthropes, or at least hyenas. ("I was so tired I couldn't think straight.") Fortunately for the existentialists, the Reuters reporter didn't actually read the Sleep article, which doesn't actually say this.
The Army study subjected volunteers to 53 hours of sleep deprivation and presented them with a battery of moral dilemma type questions ("is it morally appropriate or inappropriate to do X if Y is at stake?")
In contrast to the obvious suggestions of the Reuter's title, the study found that it took sleep deprived subjects longer to identify something as morally appropriate, but had no effect on how long it took to label it inappropriate. In fact, relative to a non-moral issue, sleep deprived subjects were able to label something as morally inappropriate faster.
Quoting the authors:
When tested at rested baseline, participants showed no significant differences between response times for scenarios judged as “appropriate” versus those judged as “inappropriate” .... In contrast, when deprived of sleep for over 53 hours, these same participants showed significantly greater difficulty judging emotionally charged MP (personal moral) courses of action as “appropriate” relative to judging them as “inappropriate.”
In other words, sleep deprivation made it harder for them to say something was right, but not harder to say it was wrong. To use a metaphor, you "know" things are wrong; but you may have to judge if they are right.
The study also looked into whether people labeled something as morally appropriate more often if they were sleep deprived, i.e. were they more permissive. First, if the subject had high emotional intelligence, sleep loss had no effect. Secondly, having an "average" emotional intelligence lead to an increase in the number of scenarios labeled appropriate: 2/10 when rested vs. 4/10 when sleep deprived. In other words, people with high emotional intelligence have stable, "unwavering" moral judgments, even in the face of sleep loss. Or, put another way: if you're clear on what you believe, sleep deprivation isn't likely to confuse you.
This is important because the Reuter's title, and indeed the psychiatric utilization of this idea, puts the ability (or inability) to make moral judgments on external factors-- "he was sleep deprived, and that impacts your judgment."   This is prima facie false; but anyway is not supported even by the very science they themselves use to back the claims.
We can set aside the debate on whether chemicals and psychosis can alter moral judgments; but I think it's fairly safe to say that if your moral judgments are affected by 53 hours of sleep deprivation, sleep isn't the problem.
-------
Note: the study also found that caffeine did not reverse the alterations in moral judgments due to sleep loss. I don't buy it; more later.

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===== ====== ===== The Last Psychiatrist: So At Least Two People Agree With Me

From the New Yorker, 6/25/07

If I could change this cartoon in any way, I'd add three words to the caption: "So I drink."
And, as a bonus, I come across this sentence in Walter Russell Mead's essay in the current issue of Foreign Affairs:
The French have long felt that Englishmen do not like women, are bored or frightened in their presence, and turn to drink as a substitute for female company.
I don't know how accurate the stereotype about Englishmen is, but the link between alcohol and women is dead on.

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===== ====== ===== The Last Psychiatrist: Social Welfare Is A Red Herring: The Return Of Feudalism

The policies sound good, and perhaps they would be, if not for the malignant intentions that motivate them.

I.

I recently received a form letter from Marcia Angell's socialist federation, "Physicians For A National Health Program," looking for support for government sponsored universal health care. It cited the usual reasons:

As physicians, we have seen the numbers of uninsured and underinsured soar, costs skyrocket, and quality deteriorate. Meanwhile, doctors drown in a sea of bureaucracy.

Etc. Ok, valid if not hyperbolic points. But that's not why she wants single payer insurance.

Only single payer would eliminate the high corporate overhead, profits, and enormous inefficiencies...
The stated reasons include reducing corporate profits. That's not a byproduct, or a necessary result, it is a reason for doing it.

II.

Another example I've used before. NPR was interviewing someone over a year ago about the high price of oil (ha!) and she asked the guy how to reduce the price, and he said he actually hoped the price would go higher, because it would curb use, decrease carbon emissions, force alternative energies to be explored, etc. Great. Her response, however was: oh, ok, and decreasing demand would be another way to hit oil companies where it hurts.

Get it? That's where she was standing, lowering prices might be good for the consumer but she didn't bother to say that. What was on the tip of her tongue was the need to punish oil companies. This woman is not stupid, she's not unaware of the complexities of energy policy-- but where her mind went immediately was how we can hurt oil companies. It wasn't incidental, it was absolutely vital that this happen.

III.

In the British Times Higher Education is an article by a Harvard professor lamenting the decline of the American student. Here's the table of contents blurb:

The banality and sense of entitlement of rich students at Harvard left John H. Summers feeling his teaching had been degraded to little more than a service to prepare clients for monied careers.
It laments the student privilege, grade inflation, consumerist attitudes, and the like. But that turns out to be only a minor gripe. What really got him:

Most of the students I encountered had already embraced the perspectives of the rich, the powerful and the unalienated, and they seemed to have done so with appalling ease.
He goes on to describe and deride this perspective, but when he chooses to cite an example-- you expect him to say something like "they urinated on homeless people" or "voted for Bush"-- he chooses this:

One of my less affluent students, the son of a postman, asked me once for advice about a financial investment.... I told him what I thought about this recommendation; but only later, when I learnt how little he had to invest ($2,000 was his total savings), did I allow myself to think I understood the significance of his question. No amount of money may be permitted to lie idle if something may be got for nothing.
This Harvard professor is angry that the guy wanted to invest. Period. "Something for nothing." Do you understand?

IV.

I suppose I shouldn't be surprised-- this nut was also angry that Harvard wouldn't let him teach a class he named, "Anarchist cultural criticism in America"-- but the main point is that this guy, the NPR interviewer, and Marcia Angell are certainly not the underprivileged. Their resentment against the system isn't supposed to be this visceral.

That's why the social welfare angle is a red herring. It's not that they want better services for the underprivileged and hurting the rich is the byproduct; it's the opposite, hurting the rich is the emotional, primary motivator, and the rest is an intellectual posture that rationalizes this resentment. This is why it's dangerous. That's why you can't side with them even if you agree with their policies. Intention matters.

Ex-Marcia these three may not be rich, but this amount of public hate and open vitriol are not expected in a properly functioning classless society.

Which simply means it's not properly functioning. Nothing new there, except for this: it is properly functioning. What's not working is the perception.

Summers is angry because he doesn't feel he could plug into the capitalist system, even though, obviously, he could if he tried-- the postman's son certainly is, with far less money or knowledge than the professor. So it's not the reality, it's the perception, but perception, confidence, is what this society is based on. Consequently, the system is failing.

The analogy is a bank run. As long as people think the bank is solvent, then it actually is. But if enough people think it isn't, then it actually becomes insolvent.

V.

So the question that needs to be answered is, "what went wrong that ordinary Americans hate people they perceive to not be in their class?"

First, education. From grade zero through college, you are told you belong to a class. Let's use the simple example of money: if you're an engineering student they'll tell you how to be an engineer, but no one anywhere tells you how to be a rich engineer. No one even tells you it is possible. If you go into the humanities, the expectation is you'll be "poor." Your future is defined by its limitations, not possibilities. "You won't starve, but you certainly aren't going to be rich." Really? Are we still in America? It seems to occur to no one to try to teach humanities students how not to be poor.

You're choosing a major and a lifetime social class. There's no fluidity-- they teach you, day one, pick your life slot. Good luck changing your mind in twenty years.

I'm not saying they should explicitly teach you how to be rich-- I'm saying they shouldn't teach you to expect to be in a slot.

Worse-- and I have seen no one anywhere make this observation, the most important one of all-- there is no generational perspective on advancement. At no point in K-16 is there even the subtlest suggestion that you should make something of yourself so that your kids can go further than you. Not as a byproduct, but as the actual purpose of all this education. No: the whole thing is about you.

Certainly people want their kids to do well, they put them in violin lessons, but what is missing is this explicit mantra: they need to go further than me. If you're a doctor reading this, answer honestly: you've mused about whether you want your kid to become a doctor or not, but do you expect them to be more than that? Not equivalent-- e.g. lawyer-- but more? Are you raising them for more, or the same?

Here's a word you will never hear taught as a goal: dynasty. No. What they teach you is feudalism: here's your fief, bring me homage.

It's not totally the parents' fault: the entire system, education and onwards, has grossly diminished expectations of its people and encourages, necessitates a self-focused, ahistoric worldview. They want you to plug into the Matrix, and then die. When you do, return all your stuff, someone else will use it.

Second, of course, is psychiatry. If you think of psychiatry as Zoloft, you're missing its scope. Psychiatry and culture are the same. It backs it, it supports it, it helps set expectations and values. It was more obvious with Darwinism or Freudianism because those were clearly articulated theories you could put in a book; psychiatry is more nebulous, but it is no less powerful a cultural force. Here's its mission statement: "you are different. And we will try hard to get you back up to the level of almost normal, but, state of the art, that's about as good as we can get."

But psychiatry doesn't just reduce expectations for humanity, it diverts attention away from real expectations, onto a pointless biologic outcome. If it really wanted to help, say, foster kids, it would say, "what are the ways we can actually change their lives? Options: we can send them to big orphanages with skill immersion programs; or we can spend a trillion dollars and give them all individual tutors/case managers to follow them every day, etc--" But since it can't have this complex debate, because it requires way too much money, it shifts the expectations to "managing symptoms."

The classic counterargument to my position is: you may be right, but psychiatry is better than nothing.

Yeah, so was your first husband. "Better than nothing" is almost always worse than "nothing." Defaulting to psychiatry legitimizes not pursuing actual solutions.

The patient is bleeding, your solution is to mop up the bloody floor so it doesn't look as bad. How long will this work? At what point do you become so deluded by the system that you think the "real" solution is better mops?

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===== ====== ===== The Last Psychiatrist: So Doctors Are Allowed To Breast Feed

A ridiculous story about a female medical student needing to go to appeals court to get extra time during the medical licensing exam so she could breast feed her kid.
Here's why it's ridiculous. If she had ADHD-- which does not exist as a physical entity but is considered an illness-- then she could get extra time. But because it's a baby-- which does exist, but is not considered an illness-- then she is entitled to nothing.

Maybe this woman is using breastfeeding as an excuse, I don't know, I don't care. It's breastfeeding-- does it occur to no one that that might be comparatively more important than, say, ADHD?
Ah, but doesn't the medical board have a valid point?
Board attorney Joseph Savage said he would appeal the ruling, which he said compromised the test's fairness and could force the board to grant extra time to other test-takers with distracting medical conditions, such as men with prostate problems.
You're right, it does open the door to this. But the problem isn't the woman who wants to breast feed, it's the inanity of an exam where such unrelated issues actually start to matter. Why should the Boards take all day? Don't give me the pat answer, "that's they way it is" or "doctors need to go through such grueling days, it builds character." Is there no more effective way to test knowledge then to see who bores slowest?
Leaving aside the question of whether the licensing exam is actually valid-- that it tests what it says it tests, basic medical knowledge; and ignoring for the moment whether a score of any kind in any way relates to your potential as a doctor; and keeping silent on whether the exam can be "gamed" (I taught for the Princeton Review for USMLE I and II for 5 years)-- why does the exam need to be all day?
It's amazing to me-- absolutely amazing, and by amazing I mean violently enraging-- that we are so apathetic that no one questions why the exam needs to be that long, that our minds find it easier to jump to whether there are alternatives to breastfeeding-- arguably the last holdout in our collective descent into narcissistic alienation.

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===== ====== ===== The Last Psychiatrist: So Ends The Ochlocracy of Medicine: How To Fix Medicaid, Part 1

Preferred Drug Lists are the bane of the practicing clinician. Instead of, for example, a psychiatrist being allowed to prescribe any antipsychotic they think appropriate, Medicaid requires them to pick from a list of only three, "on formulary" agents.

Unfortunately for doctors, the logic is sound. Unless one can show that, for example, two antipsychotics do not have the same general efficacy or tolerability across a population, than an insurance company cannot be reasonably obligated to provide both, especially if one is cheaper.

Psychiatrists complain that some patients respond better to one drug than another, but while this may be true, there is no way to predict this; try the formulary ones first. But this is just a red herring. What angers doctors is that these restrictions are an intrusion on their practice. Doctors are better able to decide risks and benefits of a medication; which drugs to prescribe, and when.

This would be a great argument if it were true. It isn’t.

The truth is that doctors are woefully ignorant of the available scientific data. As with literature and philosophy, most doctors read about the science, not the actual science itself. In general, doctors prescribe medicines not based on careful review of data, but impulse, habit, and the recommendations of “thought leaders.” (Seriously. They’re actually called that.) Prescribing medicines based on partial information or clinical soundbites may feel like "the art of medicine" but it is, in fact, a random process. It is certainly no better than having an insurance company that did review the data tell you what not to prescribe.

They also tend to practice in a vacuum. A patient’s psychiatrist and cardiologist have no link. Are the treatments synergistic? Antagonistic? Neither fully know that the other is doing.

And so, because doctors are not rigorous about their practice, someone else has to be. One of the most outrageous way psychiatrists, and possibly other physicians, waste money is to use multiple medications for a situation that could well have been handled by one. “Polypharmacy” is so common that it is actually codified in treatment guidelines, despite—and this is where insurance companies go insane—there being practically no evidence that this is ever appropriate. Why combine two antipsychotics when maybe more of one will do? It may seem plausible that two are better than one, but they aren’t. It may be true that a patient needs two drugs; but you can’t assume that. The default practice cannot be augmentation. That has to be the maneuver of last resort.

Loose practice has caused the paradigm shift. It used to be that everyone deferred to the judgment of the wise physician. No more. Now, it’s incumbent upon us to show why we need to use a treatment, not for the insurance company to trust that we know best, that we made a careful analysis of the risks and benefits—because we didn’t. We complain that medicine is being assaulted in a million different ways—insurance companies, lawyers, alternative practitioners—but the reality is it is the exact same assault: we are no longer trusted to know best.

So what to do? There is a solution. But you’re not going to like it.

Link each Medicaid patient with a pharmacy budget per specialty—money controlled by the psychiatrist. A psychiatrist can use any drug, any dose, no restrictions, but only up to, say, $10 a day. Go.

There are numerous advantages.

First, there is cost control.

Second, Pharma will inevitably cut prices in order to compete.

Third, it gives doctors their autonomy.

Fourth: it will force doctors to pay very close attention to what is, actually, best practice. They will have to be more attentive to outcome studies. They will have to predict side effects: if you’ll need to add a second drug to counteract the side effects of the first, it may be better to use a completely different drug.

Fifth: They will use fewer medicines. Two is not always better than one; but it certainly is twice as expensive with twice as many side effects.

Sixth: Pharma no longer has incentive to create “me too” drugs. They are incentivized to come up with novel, even niche, treatments.

If you really want to tax the imagination of doctors, and force a level of rigor in medicine that has not been seen since, well, since never, create a global pharmacy budget per patient across all subspecialties. This way, if a psychiatrist wants to prescribe Zyprexa, he’s going to have to discuss with the cardiologist whether that is more cost effective than the Lipitor. Wow.

The unexpected benefit is that the two doctors have to communicate. Maybe a switch from Zyprexa could preclude the need for Lipitor? Maybe? Hello? Let this communication be billable to Medicaid. $100 per “consultation” is more than offset by the pharmacy savings. There are going to be some patients who actually do require more money, more medications. In that case, the doctor can petition for increased benefits. Doctors hate doing this. Too bad. The problem was created by doctors, not by pharmacists.
Finally, to bring Pharma into the game: the first 30 days of a prescription must be piad for by the Pharma company making the drug, i.e. samples or vouchers. This way, only the drug that actually works gets paid for by Medicaid. That's gold.

It’s worth stating, for the record, that I am opposed to government interference in my practice. I don’t particularly like lawyers, either. But the sad truth is that the state of psychiatry is the fault of psychiatrists, who have failed to take full responsibility for their own education and practice. To blame anyone else at this stage is totally disingenuous.

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===== ====== ===== The Last Psychiatrist: Some Inspirational Words From My Friend In Colorado Springs

"When I was a boy of seven or eight I read a novel entitled "Abafi"... The lessons it teaches are much like those of "Ben Hur," and in this respect it might be viewed as anticipatory of the work of Wallace. The possibilities of will-power and self-control appealed tremendously to my vivid imagination, and I began to discipline myself. Had I a sweet cake or a juicy apple which I was dying to eat I would give it to another boy and go through the tortures of Tantalus, pained but satisfied. Had I some difficult task before me which was exhausting I would attack it again and again until it was done. So I practiced day by day from morning till night. At first it called for a vigorous mental effort directed against disposition and desire, but as years went by the conflict lessened and finally my will and wish became identical. They are so to-day, and in this lies the secret of whatever success I have achieved."
N.T.

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===== ====== ===== The Last Psychiatrist: Sometimes The Question Is Worse Than Any Answer

(from Parenting February 2008)

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===== ====== ===== The Last Psychiatrist: Stanford Prison Experiment Redux

it appears I'd lay there too if I were you

For those living in Antarctica, in 1974 Phil Zimbardo conducts a study, the point of which was to show

the evil that good people can be readily induced into doing to other good people within the context of socially approved roles, rules, and norms, a legitimizing ideology, and institutional support.

In other words, a person's goodness or evilness can be dramatically influenced by situation.

The first thing you should notice: my phrasing. "...the point of which was to show X." Not to study X, not to determine if X was true.

Subjects were randomly given a guard or prisoner role in a fake jail. It was supposed to last 2 weeks. He aborted it in 6 days because "too many normal young men were behaving pathologically as powerless prisoners or as sadistic, all powerful guards."

Second thing to notice: his phrasing. "...normal... behaving pathologically... powerless... sadistic..."

About his conclusions, they may imply that men are born innately good, but can be changed; or born innately bad, or born as blank slates-- but how they're born doesn't seem to matter. They can be changed, and, apparently, without too much effort. No Milgram authority figure; simply the right circumstances, $15 and a uniform.

You may want to ponder what this implies about the trivial characteristics we long to be genetic and fixed-- extroversion, anxiety, the tendency towards spending sprees-- when one's entire moral compass can be spun full around in the course of a Hampshire Halloween.

II.

The essential conclusion to be drawn from this study-- the one everyone draws all the time-- is that this can happen to anyone. "Normal" people were incited towards evil. 75 people applied; Zimbardo chose the 24 for the study who were "judged to be the most stable (physically and mentally), most mature and least involved in antisocial behavior." Also, they were Stanford students, right? Not from ASU. (zing.) Didn't matter. It's probably not necessary to point out how important this study is in psychology and the conventional wisdom. You can't have discussion about a group atrocity without this study being invoked.

There may be another explanation, and as soon as I start to write it you'll guess the rest. Zimbardo recruited subjects through a newspaper ad that said

male college students needed for a psychological study of prison life. $15/day for 1-2 weeks

It's a legitimate question: what kind of a nut signs up for that?

There's an answer. In a follow up experiment in 2007 designed specifically to answer that question, two ads were placed in newspapers, one recruiting "male college students needed for a psychological study. $70/day for 1-2 weeks" and the other, slightly different ad recruiting for "a psychological study of prison life. $70/day for 1-2 weeks."

The subjects weer screened with personality inventories, and, surprise, "prison study" recruits scored significantly higher on narcissism, social dominance, aggression, Machiavellianism and authoritarianism (but especially the first three.)

When you do a study, you get what you pay for.

III.

Zimbardo thought he was showing how a "normal" person might be made evil. He could have asked what might make a "normal" person become a passive, beaten victim-- it was the same experiment. Presumably the same forces are at work, but it is easier to believe that the distance between normal and victim is shorter than normal to evil.

But if you accept, or at least seriously consider, that there was a selection bias in the recruitment of Zimbardo's study, then there's a new finding to ponder, and I don't really know what it means.

No surprise that a group of aggressive/narcissistic people who decide they want to be part of a prison experiment need little prompting to turn into viscous guards-- but, apparently, these same aggressive/narcissistic people can just as easily be made into submissive prisoners. You might think they'd rebel more, fight back more, but apparently not.

Maybe the the real conclusion isn't how easily people with those characteristics can be pushed into an aggressor or victim status, but their tendency to identify with a group, whatever it may be.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: STAR*D Augmentation Trial: WRONG!

This is what a $150 subscription to the NEJM gets you:
From the abstract:
Conclusions Augmentation of citalopram with either sustained-releasebupropion or buspirone appears to be useful in actual clinicalsettings.

I can't be the only person who actually reads the articles and not just the titles, can I? There has to be at least one other person?

565 Celexa failures (i.e. did not achieve remission) from the previous STAR*D trial were then randomized to Celexa (avg dose 54mg) + Wellbutrin or Celexa + Buspar. 30 percent of the augmented patients (either Wellbutrin or Buspar) achieved remission.
From this it is concluded "These findings show that augmentation of SSRIswith either agent will result in symptom remission."
How the hell do you conclude that? Is it a mere coincidence that the remission rates of Celexa+Wellbutrin in this group were the same as Celexa alone in the other study (30%)-- and the same as almost every other monotherapy trial for every other antidepressant?

In other words, how can you be sure it was the combination of Celexa+Wellbutrin that got the patients better, and not the Wellbutrin alone? What would have happened if you had given these patients Wellbutrin but taken them off Celexa? They would have done half as well? Are you sure?
I'm not saying that it might not be true that two drugs are better than one, I'm saying that this study doesn't show that. If anything, this study actually supports switching as a strategy (i.e. fail Celexa, so switch to Wellbutrin)-- because two drugs are not proven here to be twice as good as one alone, but I can certainly prove they carry twice as many side effects and are twice as expensive.

Here we have a massive expenditure of tax dollars that will undoubtedly lead to treatment guidelines that will be clinically misleading and economically wasteful. How much did the NIMH pay for this? And for CATIE? I'm not a Pharma apologist, but what was wrong with forcing Pharma to pay for their own studies which we get to pick apart? These government sponsored studies are no better. Gee-- the generic came out on top?

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===== ====== ===== The Last Psychiatrist: Star-D Study Participants: What's Wrong With These People?

I don't even know what to make of this:

4041 patients show up and consent to be in a massive antidepressant trial, and almost 25% can't even score a HAM-D of 14? (7=complete cure.) Who are these people? What were they thinking?

And then of the ones who actually stay to participate (N=2876), their average HAM-D is 21? For two years?

And Celexa cures a third of these patients? Half of them in less than 6 weeks? After two years walking around HAM-D =21? Cures? Celexa? 40mg? Hello?

Remember, this is open label. These people, who presumably have been in psychiatric treatment for a long time (mean length of illness 15 years), know that they are taking 40mg of Celexa.   Not a new experimental drug with a new mechanism of action. Celexa. 1/3rd get cured. After all this time.

BTW, the people who failed this Celexa study get moved into Star-D II. What is the relevance of this? Well, in this study 63% were female, 75% were white, 40% were married, 87% were high school grads or greater, 56% had jobs. It is the opposite of this demographic that is most likely not to have gotten better.

Evaluation of Outcomes with Citalopram for Depression Using Measurement-Based Care in STAR*D.

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===== ====== ===== The Last Psychiatrist: Still Alive
WHERE DID YOU GO?

I flatter myself by thinking you are asking this question. I am writing a book of and about porn.

IS IT ANY GOOD?

Not sure. I am trying my best. It's a lot of work, complicated by relentless self-doubt. The good news is I am drinking more.

ALMOST DONE?

Yes, guy who asks all the right questions.

WILL YOU THEN RETURN TO THE BLOG?

Yes. The blog is very good practice.

IN THE MEANTIME, DO YOU RECOMMEND ANY OF YOUR OLD POSTS?

No. Read at your own risk/tolerance, I distance myself from everything older than, say, the last four or five posts. Everything else is thinking out loud, work in progress. I could go back and try to revise the old posts, but there's no point. Life is change, have to keep moving forward.

IF YOU HAD TO PICK ONE OR TWO...?

The Second Story of Echo and Narcissus and The Boy Who Cried Wolf.

WHY A BOOK?

I didn't want to put a porn story on the blog, I felt there should be a buffer. Wait-- are you asking me why I didn't just shoot a sex tape? Huh.

SO YOU WROTE AN ACTUAL PORN STORY?

Yes.

HARDCORE PORN?

Yes.

IS IT HETERONORMATIVE?

Sigh.

The book is in two parts. The first part is a straight up porn short story. There's penis and vagina and lots of cum/ming. I have deliberately not written the story "well", whatever that means, I am imitating the flow and style of that kind of story. I didn't try to make it sensual or unusual; while it is hard core pornography it is a fairly vanilla story-- boy vs. girl, no vampires, no one dies-- obvious in its language and plot and etc. My goal wasn't to elevate the genre but to photograph it. I did this so that you could assure yourself that there is nothing meaningful there, no symbolism-- just explicit porn. And then to business.

DO YOU TRY TO EXPLAIN THE PSYCHOLOGICAL MECHANISMS OF PORN?

No. It's not the deconstruction of a text, it is the interpretation of a dream. I make no attempt to explain what porn means in general, only what it means to you.

HOW CAN YOU KNOW WHAT IT MEANS TO ME?

The important thing is to say whatever comes to mind.

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===== ====== ===== The Last Psychiatrist: Stopping Meds Does Not Cause Relapse

Glick and friends did a small study finding-- big surprise-- stopping some of the medications when a schizophrenic is stable does not drive them into a horrible suicidal relapse. Some even got better.

Naturalistic study: 53 stable schizophrenics on antipsychotics were tapered off of antidepressants or mood stabilizers and followed for up to two years, using CGI as the measure (sigh.)
20/21 patients tapered off antidepressants were unchanged or (n=3) better; the one who did worse was an 18 yo WM on 300mg Wellbutrin.
9/12 tapered off mood stabilizers were unchanged; the three who did worse were all WM (actually, they were all white) on Lithium 600, Tegretol 1200, or Neurontin 1200.

So while that is very encouraging though only preliminary, what got me about the paper was this sentence:

"There are definitivew data in general medicine showing that combintations are much more effective than monotherapy, supported by many randomized blinded studies with a good understanding of mechanism--"
Seriously? Does he have access to some other internet than I have? What are the references?

"-- in chronic pain, for example.16"

Oh, chronic pain. I see.

FYI: Glick also did a study on suicidality, finding that the study that showed Clozaril's anti-suicide property (InterSePT) had nothing to do with the concomitant medications (mood stabilziers, antidepressants or benzos).

(16) references a morphine +/- neurontin for pain paper.

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===== ====== ===== The Last Psychiatrist: Study Finds Chocolate Causes Depression. In Other News, These Kinds Of Studies Cause Insanity

all three of us are crying inside

From the Abstract:

Results Those screening positive for possible depression(CES-D score >16) had higher chocolate consumption (8.4 servingsper month) than those not screening positive (5.4 servings permonth) (P = .004)

Oh god, please, I need a drink.

The authors are very careful to assure everyone that they don't mean to imply that chocolate causes depression, this is just an association.   Let's not jump to conclusions.

II.

Chocolate lovers 'are more depressive,' say experts- BBC

The More Chocolate You Eat, the Higher Your Risk of Depression, Study Hints-- ABC News

Chocolate And Depression Go Hand In Hand- CNN. First sentence:

When Dina Khiry is feeling a bit down, she reaches for chocolate. "I like Reese's peanut butter cups, Hershey's bars, and chocolate cake batter," says the 24-year-old public relations associate. "I feel better in the moment -- and then worse later on, when I realize that I just consumed thousands of calories."
Does anyone understand that there is barely any chocolate in any of those chocolates? Even the Hershey's Bar, which has the highest of all of them, has 10% chocolate liquor (smashed cacao beans.) And if the box doesn't say "milk chocolate," then all bets are off. White chocolate has plenty of cocoa butter, but no chocolate solids. And no caffeine, theobromine, or flavinoids. Still counts, though, right?

And see the phrase "cocoa processed with alkali" in the ingredients of "chocolate cake batter"? Alkalinization (makes it easier to mix) drains the cocoa of the flavinoids. Is it going to "work" the same? That's like saying "rum processed with fire" will have the same mood stabilizing effects. IT DOESN'T. I'VE TRIED IT.

simulacra

The study, as best as I can tell, did not ask them what kind of chocolate they were eating, it only measured "ounces of chocolate candy." Is an ounce of chocolate covered cocoa beans the same as an ounce of Hershey's Krackel, which has no cocoa butter (all vegetable oil)? (1) The only thing they have in common is a disdain for fair trade.

Can you imagine if someone did a study about mood and alcohol consumption, and measured it as "ounces of an alcoholic beverage" but didn't specify beer, wine, spirits, or rubbing?

III.

On the one hand we have no idea how much chocolate was in a serving, if there was any at all.

On the other hand we have "depression." What's a CES-D?

It's a 20 question 0-3 survey that people answer about their mood over the past week. Think about this.

The scale doesn't diagnose depression at all; you could have had 30 suicide attempts in the past year and happen to have had some sex this week and come out fine on the inventory; or, you could have been the merriest gal in the whole wide world until your stupid boyfriend dragged you to see Avatar and now you're calling a hotline. So?

Can you really link a chronic behavior (e.g. eating chocolate) with a ===== ====== ===== The Last Psychiatrist: Subtypes of OCD

CNS Spectr. 2006 Mar;11(3):179-86.

The authors examined the difference between two (theoretical) subtypes of OCD symptoms. Based on the earlier work of Lee and Kwon, obsessions can be divided into autogenous and reactive.

Autogenous: occur without identifiable or likely stimuli; repetitive; disturbing;
Examples: "sexual, aggressive, or immoral thoughts, images, or impulses." The sudden obsession to rape; or seeing a red shirt, which signifies raping.
Coping strategy: suppress these thoughts

Reactive: caused by identifiable external stimuli, including thoughts of contamination, asymmetry, loss; are realistic;
Coping strategy:reduce anxiety (e.g. wash hands.)

They found some interesting differences:

Autogenous obsessives were more likely to be male, and older (34) and have older ages of onset (27);

Reactive obsessives were more likely female (60/40), younger (27) and younger age of onset (19).

No difference in either group in education or marital status; nor were there any major psychiatric comorbidities.

But autogenous obsessives rarely (1%) dissociated; reactives did dissociate (10%).

A few points. That aggressive/sexual thoughts go with males is no surprise. But that they are found in the older people is interesting. If you can see how primitive thinking occurs in reactive OCD, it makes sense they would get their symptoms at a younger age. It is known that cleaning and checking obsessions are associated with an earlier age of onset.

The prevalence of dissociation in reactive patients- or the absence of it in autogenous patients-- had already been suspected. Checking and symmetry symptoms (associated here with reactive type) had already been found to be more commonly associated with dissociation. (Personal diversion: my own clinical experience with pedophiles supports this-- that those with sexual obsessions are fully conscious of them; obsess over them, are familiar with every nuance. They know to molecular detail what the child looks like, how it moves; and are totally aware of their own behavior at every step of the molestation, even when they pretend a quasi-dissociative experience as a defense. They wouldn't dissociate during the acts because, in effect, it defeats the purpose of committing the act.)

Additionally, in other studies, Lee and partners (Telch, Kwon, etc) found that autogenous obsessions were more associated with schizotypal personality than to other OCD symptoms themselves (while reactive obsessions had no association with schizotypal.) 1 The authors use this finding to support the idea that autogenous obsessions represent cognitive issues, while reactive represent behavioral ones; autogenous obsessives obsess; reactive obsessives are compulsives. This is further supported another study finding that on Rorshach, autogenous obsessives, like schizophrenics, have severe thought disorder, while reactive obsessives do not.2 The belief that merely thinking a thought could make it true (formally called the likelihood bias of though-action fusion) sounds like the magical thinking in schizotypal, and in fact TAF is seen in schizotypals 4 1. It would be interesting if it could be investigated in autogenous obsessives versus reactive obsessives separately, the hypothesis being that autogenous obsessives display likelihood TAF, while reactives do not.

Clinically, it may be fair to say that people with autogenous type obsessions share schizotypal features, and cognitive/perceptual distortions, while reactive obsessions go with OCPD features and compulsive behaviors. So, do antipsychotics help autogenous obsessives (and not (or better than) reactive obsessives?)

In line with this, there is some evidence that schizophrenics and OCDs share some neurodevelopmental pathology. For example, using fractal dimension and CSF volume, one could accurately categorize schizophrenics or OCD patients, vs controls, with 90% accuracy.3 It would be interesting to see if these obsessives, based on brain pathology alone, could be distinguished between autogenous and reactive types. I suspect the answer will be yes.

1. J Anxiety Disord. 2005;19(7):793-805. Epub 2005 Jan 5.
2. J Clin Psychol. 2005 Apr;61(4):401-13.

3. Neurosci Lett. 2005 Aug 12-19;384(1-2):172-6.

4. Behav Res Ther. 2005 Jan;43(1):29-41.

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===== ====== ===== The Last Psychiatrist: Suicidal Patients' Access To Their Psychiatrist
In the tradition of Robert Kagan and the folks at Policy Review, Robert Simon, MD defines foreign policy for the next century.

Robert Simon, MD is one of the big forensic psychiatrists in the country, along with Park Dietz, Robert Sadoff, etc. In many ways, he sets standards of forensic practice. He frames the debates: he (and others) decide what words we'll use, what principles are in vogue, how clinical data are applied in a legal context.

Which is why his latest article, "Suicidal Patients' Access To Their Psychiatrists" is-- no other way to say it-- a disaster for psychiatry.

His article can be summarized by the large red font excerpt in the middle of the page:

Standard of care requires that psychiatrists or their designees be accessible to suicidal patients and that they respond within a reasonable time.
He gives examples of what he feels constitutes standard of care practice:

In solo practice, the psychiatrist or covering clinician must be accessible 24 hours a day, 7 days a week, by cell phone, pager...Twenty-four hour coverage for patient emergencies is an established... standard of care.

First, I'll go on record and say that I think he is wrong.

On a simple level, the problem with the article is that he does not distinguish between "standard of care" and "best care."

Standard of care is defined in many ways, but here are two good ones: "customary practice" or "reasonably prudent similar health care provider."   They're not the same. "Reasonably prudent" is not based on number of docs doing it. Even if 99% of docs are doing X, it could still be substandard care.   Which is, in effect, what he is saying: whether or not most psychiatrists do this is irrelevant-- they should do it.

So the trick is this: in the guild system (yes, like a thieves' guild) of medicine, who decides what the standard is? What a "reasonably prudent" doctor would do? In some cases, it's obvious (e.g. no sleeping with patients no matter how hot they are) but ultimately the answer is there is no answer: it's decided in court, in a duel between experts. And academic articles are the ammunition.

So while I disagree with him on what is standard of care, the real problem with the article is more serious: by writing this article, Simon isn't merely reporting the standard of care, he is causing this to be the standard of care.

II.

Believe it or not, I am not completely without empathy for other people.

I recognize the feeling of crisis, of vertigo-- nausea-- that some have when their bodies and their minds tell them they have to GO NOW-- or, for others, that it's simply better and easier (just) to go...

That is a structural problem, a logistic problem, for psychiatry: how can we deliver effective and efficient care to those who, almost by definition, need us when we are not available? This can be solved with outcome studies, with data, with debate.

But the issue right here is that this discussion has been effectively commandeered by Simon, and others-- others, BTW, who do not actually treat any patients in crisis. No one asked a regular psychiatrist; no one did a survey of the exiting practices. He just said it.

He may be right that this should be standard of care, but he should have to defend his position. (For example: Is it true that the suicide rate is lower when there is 24 hour access?)

But by writing this, he's not asked to defend why he's right-- he just established the default position. The onus is now on everyone else to explain why he might be wrong. The analogy is, well, Iraq: what happens when others in government-- who have never seen a war, let alone fought one-- tell you how and when to conduct a war?

You're nodding? Don't, because here's the answer: they get voted back into office, again. Policy is always set by those with little direct investment in it; because those who have most to gain or lose have so little time, and so little access to the debate itself, that inertia takes over.

III.

I don't blame Simon, and no, I don't blame Bush either. It's not exactly their fault. They are repeatedly given mandates to decide policy, and so they decide based on their principles (yes, Bush, too.) They believe they're right-- and no one is around to tell them they're not.

Simon thinks he's right; and, for support, he offers the "top" psychiatrists-- academics. Who, of course, don't have to deal with 24 hour coverage, either.

You can't tell Dr. Simon that 24 hour coverage is physically impossible. For a solo practitioner with 100 patients, if 1% have a crisis, he's dealing with 1 phone call.   In a city, community mental health clinics treat 3000-10000 patients. If 1% have a crisis, that clinic closes.   In states like Idaho, where there is one psychiatrist for a gigantic area-- sometimes even one NP who travels-- it's impossible.

But much more importantly, you would be scared to tell him he's wrong. You can write a letter to the Psychiatric Times and say, yo playa, you're wrong-- but what's the point? His article is in pubmed, yours isn't. But you sure as hell wouldn't dare to tell him that within a mile of a courthouse. "Dr. Simon is wrong, no community clinic in the Inland Empire does that."   Oh? You just abandon your suicidal patients to the night and city streets? Let the drug dealers and roaches care for them in a crisis? Maybe the care in the Inland Empire isn't very good? According to Dr. Simon, it's standard practice everywhere else. Perhaps you should stop torturing your patients with your incompetence?

So you nod your head in assent in public, but stay quiet, hoping no one will ever scrutinize your practice.

IV.

Simon's logorrhea has a side effect: he's changing social policy. I know he doesn't mean to, I know he would deny it, but it's true.

This is how it goes: the Law looks to Psychiatry to shed light on behavior. Society watches this interaction and adapts.

Simon makes a specific point that leaving a "if this is an emergency, go to your nearest ER" outgoing message is not acceptable. But then why is it for primary care? If you have a heart attack at 2am, can you sue your doctor because he wasn't available and you didn't know you had to go to an ER? Society hears him, and it says, "oh, people with psychiatric disorders are out of control. They need 24 hour coverage."

Forensic psychiatrists have massive power, they decide how psychiatry is applied to the law, to the public. They make things true, not least because no one checks their work (except possibly the other expert.) And Society has little reason not to accept it.

So Society infers: psych patients can't think clearly. They cannot be responsible for themselves, even when they're doing fine, because they might suddenly not be fine-- so someone has to be there around the clock to catch them.

And another steel I-beam is riveted to the infrastructure of a custodial society.

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===== ====== ===== The Last Psychiatrist: Who Died?

Here is a suicide statistic:

"Suicide is the eighth leading cause of death in men."

That's useless, because there is no context. Other useless statements are: the risk is higher in psychiatric illness; the risk is higher the more previous attempts; men have higher rates of sucide than women, etc.

Here are some statistics (1999, 2001 and 2003-- they're all the same) which may help you.

In the US in 2001, 30,622 people died from suicide.   Yes. That few.
24,672 were men. 5950 were women. (That's 80/20). In the whole world (WHO 2000), it was about 815,000.

5395 were over 65. (85/15 males to females)
3971 were 15-24. (85/15 males to females)

So 70% of all suicides are adults.
73% of all suicides are white males (20,000+). To put it in perspective, in 2003, the number of black women who suicided was 358.
Guns were involved in 55% of all suicides; 60% of the men's, and 73% of the elderly's, and 54% of youth's.

In other words, mostly white adult males die.

White men over 85 have the highest rate given their popualtion (54/100,000), vs. an overall rate of 10.7/100,000 (.01%) But this number of suicides is so small that the statistic doesn't help you.

So the real risk factors are white males with a gun.

I should also point out that 30,622 is a really small number of people-- even though it is almost as many as homicides (20k) and AIDS deaths (14k) combined.

How about suicide attempts that don't result in death?

Well, there are a lot: in 2002, 132,353 were hospitalized for a suicide attempt, and 116,639 were seen in an ER and released. But here's the thing: they didn't die.

The problem with our suicide assessment is that it screens for attempts, not death. And while non-psychiatrists might be surprised to hear this, a whole lot of people commit impulsive suicidal acts with no or little interest in actually dying. Psychiatry cannot do much to stop these acts, nor should it be responsible to do so. A psychiatrist should be no more responsible to prevent these parasuicidal acts than an endocrinologist is to guarantee that the patient takes their insulin. If psychiatric illness-- that's major Axis I-- so impairs their reason that they don't know what they're doing, can't stop, etc-- then it's our responsibility, just like, given that same patient, it's the endocrinologist's. Otherwise, it is not.

We spend a lot, a lot, of money and time hospitalizing people who are not going to die. A not insignificant portion are outright malingerers, and everyone knows it. The rest may be at risk, but they may not be best served in a hospital.

So we can either spend our time and resources on preventing suicide attempts, or on preventing the 30k actual suicide deaths. It's not the same thing.

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===== ====== ===== The Last Psychiatrist: Psychiatrists On The Wrong Side of Civil Rights, Again

Hunter college caves to lawyers.
A student takes a bunch of Tylenol in an OD attempt, and after 4 days inpatient returns to her dorm to find she has been evicted.
The article makes it sound as if Hunter College kicks you out of school if you attempt suicide, which wouldn't necessarily be improper, but it's also not true. Hunter College's housing contract says you can't live in the dorms if you have a suicide attempt. That's a little different.
So the student sues, and Hunter decides to settle. Her lawyer gloats:
“We’re pleased that Jane has been compensated for the college’s discriminatory treatment based on the stigma attached to a mental illness,” said David Goldfarb, one of the law firm’s attorneys representing her. “If Jane had been hospitalized for mononucleosis or pneumonia, I am confident that she would have been welcomed back to her dorm,” he added.
Well, gee, maybe a suicide attempt made volitionally, with a good chance of happening again, is a little different than pneumonia? Stigma of mental illness? So she was evicted for being on Zoloft?
The lawyer for the Bazelon Center for Mental Health Law , who should know better, says,
"Schools that exclude students who seek help discourage them from getting the help they need, isolate the students from friends and support at a time when support is most needed, and send students the message that they have done something wrong.”
Hmm. I thought Hunter was a college, not a daycare? Since when is it a school's responsibility to ensure adequate access to friends? Is it responsible for finding them mates as well? The problem with this statement is its logical conclusion: when can a school exclude students who seek help? Never? Let's say the next time she tries suicide by turning the gas on, and she blows the dorm up. Oops?
The most dangerous quote of all is from someone who really, really should know better, but obviously doesn't:
[Rachel] Glick, who is also associate chair for clinical and administrative affairs and a clinical associate professor in the Department of Psychiatry at the University of Michigan, emphasized that "universities should be open to being informed by psychiatrists and other mental health professionals about what to do to enhance the care of the students, rather than just thinking about protecting themselves from lawsuits."
So let me get this straight: the university should ask the psychiatrist about whether the person could stay on campus or not?   Any psychiatrist out there who wants that liability football?
College: So now that you've evaluated her, should she be allowed to return to the dorm?
Psychiatrist: Huh?
College: Is she going to kill herself again?
Psychiatrist: How the hell would I know that? I can't predict the future.
College: But you all told us we needed to seek your advice.
Psychiatrist: Hey man, don't try to pin this on me. I'm going to lunch.
Interestingly, the Psychiatric News article doesn't mention last month's case where the parents of Charles Mahoney sued Allegheny University because Charles was not put on mandatory leave of absence while he battled depression for two and a half years.
Everyone wants it their way; sue when you don't get your way, logical consistency be damned. Has it now become outrageous to say that the liability for a suicide attempt and its prevention lies entirely with the person attempting it?
(Addendum: many angry at my post, so I refer to the specifics of the case itself.)

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===== ====== ===== The Last Psychiatrist: Suicide Note Revisited: Formulation

Previously, I had written an (what I thought to be outstanding) article about suicide documentation. The main point was a refocusing of the note away from Objective and towards Assessment. It now occurs to me that what I was really trying to get at is the lost art of writing a psychiatric formualtion of a patient.
The reason we don't do formulations anymore-- they're not even taught in most residencies, certainly not in mine or now to the residents I supervise-- is because it's not clear what the formulation is supposed to do. Doctors get overwhelmed by the psychodynamics of it and can't seethe practical utility. Someone brought them twenty ingredients but didn't tell them what they were cooking.
A formulation is different than a diagnosis or description of the patient. The formulation seeks to convey the relevant parts of a patient so that you can predict how a patient might behave in future circumstances.   By way of example, a formulation is similar to a "profile" in crime movies. When they say things like, "he's going to want to tie the women with piano wires, because he's a schizophrenic who was forced to sleep in a tuba..." that's a formulation (sort of-- you get the idea.)
The formulation helps prediction by linking the various aspects-- seemingly unrelated, perhaps-- of a patient's existence. It's the stuff you know is relevant, but DSM and standard psychiatry have no room for. What does it mean if I tell you an inpatient brought with her fuzzy bunny slippers? That's goes in the formulation. A statement such as, "the strong family history of bipolar disorder, along with his chronic alcohol abuse and prior suicide attempts, and the pending divorce and custody battle, and his recent apostasis from Catholicism put him at higher risk for suicide" is the type of sentence I want in the Assessment-- and it is precisely a short example of a "biopsychosocial" formulation.
Note the importance of having all factors together, as opposed to individually. It sets up the logic; it lets the reader know, immediately and obviously, what you were thinking. This is very different than writing in one part of the note, "Fam Hx: strong bipolar;" and in another part of the note, "Chronic alcohol abuse; history of multiple suicide attempts;" and in another place, "patient divorcing, and custody trial is next month." Putting it that way, in the classic H&P format, forces the reader to have to infer.   Put in a biopsychosocial formulation, and the reader gets it instantly without even reading the rest of the H&P. That's what you want.
Interestingly, the term "biopsychosocial" was coined by George Engel, psychoanalyst(?), who in 1977 made the startling observation, "The dominant model of disease today is biomedical, and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness."
[It] would seem that psychiatry would do well to emulate its sister medical disciplines by finally embracing once and for all the medical model of disease. But I do not accept such a premise. Rather, I contend that all medicine is in crisis, and, further, that medicine's crisis derives from the same basic fault as psychiatry's, namely, adherence to a model of disease no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry.
Plus ca change...
Engel, like others, had understood that somatic symptoms such as pain, weakness, etc, and autonomic symptoms such as reflux, tachycardia, etc could be symbolic expressions of emotion or conflict.   How could the Objective portion of a note ever explain why you discharged a person with acute bilateral leg paralysis? It can't-- but a biopsychosocial formualtion can.
As per Engel, the main question such a biopsychosocial model seeks to answer is why some patients experience an "illness" while others experience a "problem of living." Importantly, the patient himself doesn't often know: the patient defines it as an illness recursively by whether or not he "needs" a doctor, and not by an actual understanding of what's wrong with him. It's the doctor's job to decide whether it is actually an illness or a life problem, and then properly re-educate and re-train the patient.
Note that in my post about suicide documentation, the hypothetical patient was not malingering. He believed he needed to be hospitalized because he was suicidal. But when you discharge such a patient from the ER, you are thinking that the person will not die-- the suicidality is an expression of something else. This is Engel's dichotomy. The patient thinks one thing, you think another-- it's your job to explain to the patient what's really going on, AND explain to the reader why you did what you did.
Typically, formulations are taught, in my opinion, backwards, so students "don't get it." You're taught to start with what's going on now, then describe what historical factors that made the patient who he is (including genetics, upbringing, social stressors, meds, etc),; then psychodynamic explanations, and then your proposed treatment and how you predict the patient will respond.   I think it is easier to go backwards. First, decide what you think is going to happen in the future (will commit suicide, won't relapse, is a mania risk, etc) and then explain what it is about his past and present that makes you think this. In this way, you're writing the formulation with a purpose.

"Joe came to the ER for suicidality after he got drunk after getting divorce papers.
Joe takes rejection very hard, and characteristically when the rejection is new, he doesn't spend time to think things through. He exhibits poor judgment (give examples here or in Objective), is impulsive (examples), and also does things which further reduce his judgment and raise his impulsivity (like get drunk.)
Joe has several narcisissitic features . For example, importantly, his suicidality is directed at his ex-wife. The point of the attempt is that she find out, that she know he is feeling hurt. If it was guaranteed that she would never find out, he would not attempt suicide because it would have lost its meaning. He needs her, or at least someone, to acknowledge his pain, and see him as the person he is trying to portray. As we talked, I made it clear that I did see he was hurt, and I understood the rejection--how it not only was a loss of a wife, but also a hint that he himself was unworthy of her. We discussed that she was entitled to leave him, but that she could not deterine his value."

etc, etc. You see how even without an Objective portion, the narrative in the Assessment is quite clear. The reader understands what you were seeing and thinking.

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===== ====== ===== The Last Psychiatrist: Sunshine and Suicide

Would you predict suicides increase in the sunshine/summer or darkness/winter?
Obviously, if I'm asking...
A Greek study-- and Greece has one of the lowest suicide rates in the world, about 5/100,000 (U.S. is about 17) with two major findings:
1. Suicides in the northern hemisphere, across 18 very diverse countries (Europe, Eastern Europe, Japan, North America,) peak in May/June, with a relative risk 1.08-1.5.
2. This peak is actually due to the amount of sunshine. More sun=more death.
#2 seems a stretch to me, so I looked it up further. Wow.
Same guys, find that there was no relationship between suicide and that day's sunlight; but there was a strong correlation with the past days sunlight. There were several specific sun/day-suicide interactions, but in general for males that past 8 days and the day before, and for females that past 4 days (but not he day before) were correlated to increased risk.
If you consider that the solar radiance in June is 26 MW/m2, and December is 6 MW/m2, then the risk of suicide increases 3% for every 1 MW/m2.
Others have found the same. An illustrative example is the Chile study finding the springtime peak of suicides, but this effect was absent in the north, which is closest to the equator and thus has the least seasonal variability (Chile is a strip that runs up and down the western part of South America.)   Interestingly, other equatorial regions have failed to find seasonal suicide links (e.g. Singapore); some have even identified a reverse pattern in the southern hemisphere. And urban areas seem to have a less pronounced or absent effect.
This is all quite interesting, but in order for it to be useful we have to show that there isn't another obvious explanation. Here's one: people kill themselves in June because there are more available tools. Jumping off a building, outdoor hanging, drowning, all prefer better weather. For example, you don't mull jumping off a building during a week of rain.
Now you could counter that such a suicidal person would simply come up with something else (e.g. OD) but that's not what happens; suicides are very specific and personal acts. The jumper doesn't instead use a gun. (Consider that people with multiple suicide attempts use the same one or two methods each time.) If two methods are similar, however, then I think such a move could happen. But if the person is considering drowning, then an OD is probably not an option, because drowning means something, it ihas unconscious significance, and that can't be ignored.
I might even propose that non-OD and non-self-cutting suicides are just as much about the act as about the desire to die. When you get drunk and then stab yourself in the abdomen 45 times, you're communicating something as well as trying to die.
Following from this, it has been observed that there is no seasonal pattern to non-weather related methods: cutting, OD, gassing, (i.e. non-violent methods). There's no seasonality (skew towards winter) to jumping in front of a German subway, which is thankfully free of sunlight's evil effects.
So if it rains for a week, instead of moving to another completely different suicide method, I believe they would simply postpone (i.e. continue to ruminate about it) their attempt, unless a similar method is available.

BTW, this is about completed suicide, not suicidality or suicide attempts, for which I have no idea about the seasonality.

I bring this up because of the discussions I've had, especially with the residents at my hospital, on the extent of volitional control in suicide. I say it is a cognitive process and not necessary outcome of a disorder, and the idea that sunlight or weather can influence the timing or method of a suicide goes along with that.

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===== ====== ===== The Last Psychiatrist: Superman's A Baby, But He's Still Superman

it's so pretty

So this is how you miss the signs. Pay attention, it's a kind of charade.

The boy is at a kid's birthday party and the kids are 7, and they're bowling because nothing suits 7 year olds better than perfect spheres made of depleted uranium and 45 minutes of waiting your turn.

A girl wearing a tiara bowls a 71. Superman-shirt bowls a 76. A future parole violator quits after two gutter balls because this game sucks, an odd assessment since it's his party. His mom is showing another mom texts from a man who is not his dad. The boy bowls a 101. Granted, he double underhanded it the whole time, but so what.

Princess says to the boy, "You won!" The boy tries to suppress a hesitant, humble smile beaming with incredulous pride. Princess gives him a hug and he almost cries.

Superman says, "No you didn't."

"Yes he did," says Princess.

"Yes I did," says the boy.

"No you didn't," says Superman. "You got the highest score, but you didn't win."

I'm not familiar with sports, let alone bowling, so I don't really understand the scoring. Is bowling scored like blackjack, where you can have more points but still lose? Or is bowling pretty much like football, where more points= the other team's cheerleaders? Which would mean either Superman is running a short con or he got into his parents' mushrooms.

The boy says some words, but what he says is irrelevant because the boy's parents are less like parents and more like Idiots and Idiocy can overwhelm everything but death, and death can overwhelm everything else but denial. The boy's parents are proud of the boy, they want him to feel good, so they jump in: you did win! you are the winner! They are patting him on the back for his win, sure, they may suspect it was a fluke (so he crossed the line a little) but self-esteem is what's important here, right, at this age, right? This is a big deal for the boy, he won, f-i-s, come on, let him have his moment. Have some more cake! Have another juice box! Hey, everyone, come give the boy a high-five! Don't pay any attention to Superman, he's just a Greenie Meaneenie Jealous Butt Crybeanie, he doesn't like it when anyone's satisfied.

Yeah, but Superman is telling the Idiots something important. He is telling them that based on his prior history with the boy, based on what he knows of the boy, telling him he didn't win might actually work. He wouldn't have tried this on the Princess, or his parents, or some stranger with a beer gut and an ankle monitor-- no, he tried this on the boy because he had a feeling he would fall for it.

Which means that the correct lesson the boy's parents could have taught him was what is it about Superman that makes him act that way? Or more importantly, what is it that the boy does to make Superman think he can manipulate him? But the one they went with, the one that will make him neurotic for the rest of his life, is that he's a winner.

But he might not be. Not if Superman has anything to say about it.

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===== ====== ===== The Last Psychiatrist: Swallow This: How Seroquel XR Works, Part 3

if you could only see the truth

Part 1
Part 2

Now let's stop asking how, and ask what: what does this drug actually do?

FDA:

Major Depressive Disorder sNDA Submission
The FDA approval of SEROQUEL XR for MDD was based on a supplemental new drug application (sNDA) comprising findings from two Phase III, placebo-controlled studies that assessed the efficacy and safety of once-daily treatment with SEROQUEL XR as adjunctive treatment in patients with MDD.

Note the word adjunctive. Two trials showed its efficacy as an adjunct. Like Abilify, Seroquel is only indicated for use as a supplement to a failed/failing antidepressant. Maybe it's a necessary combination of a serotonergic effect plus (a non-existent) noradrenergic effect, or some other synergistic mechanism; but it's an add-on, so get adding.

An adjunct-- to what?

There's your data, it's one of the two trials the FDA used to grant the indication. The other trial's data was nearly identical. (1)

Seroquel was tested as an add-on to SSRIs, and also Effexor and Cymbalta. (The top line is placebo + SSRI/SNRI.) If we believe that at the doses used Effexor and Cymbalta are blocking the NET, and Seroquel at 150mg is doing the same, then why would we expect the addition of Seroquel to be of any use? They're both fighting for the same site, only one can bind, so? You wouldn't mix Paxil and Zoloft, would you?

So either the NET isn't relevant here; or, if it is, then those patients on Effexor/Cymbalta + Seroquel will not show greater improvement (e.g. as compared to Celexa + Seroquel). And the pooled data you see above will appear less impressive because the Effexor and Cymbalta patients dragged the overall average down.

Or, more simply: if they did the study only with SSRIs, maybe the augmentation results would have been even better!

So either the FDA is wrong you shouldn't mix it with Effexor/Cymbalta, or you should because the FDA is wrong about the mechanism. Good luck, have a drink. Your next patient is the dumpster guy from Mulholland Drive.

You're frightening me with your talk of dumpsters and intimations of rum.

Drink up.

This is from the promotional slide deck that Astra Zeneca uses to detail doctors, showing the results of the two trials.

Take a good look at this slide, and compare it to the one above, from which it came. Do you see anything weird? Take minute.

Stop looking at the data curves. Stop looking at the p values. What do you expect to see there? You already know it's going to beat placebo or else they wouldn't have made a slide. Do you really think you're going to discover something there?

This slide is an illusion like the impossible fork, you want to see this as a representation of something else instead of seeing it for what it is.

I'll give you a hint:

What happened to studies 1-5?

Undoubtedly, your first thought will be that AZ hid the data. I wish that was true.

This is a promotional slide. The purpose of it is to push Seroquel. That means that nothing on it is not either compelled by the FDA or on purpose to get you to believe. They are accurately labeled studies 6 and 7 so that there so doctors ask about the other 5 studies. Why do they need doctors to ask? Because the FDA forbids them from mentioning them.   So strict is this ban that the AZ reps are not even told by the company there are 5 other studies, so that they don't accidentally mention them. I am not exaggerating. The reps don't know.

You know what makes me happiest? When the government considers certain information so disruptive that it not only doesn't it tell the citizens, it doesn't even tell other members of the government. So that the only people who know are the heads of the government, and the heads of a for-profit corporation.

There's a word for that kind of thing. But anyway.

So what were studies 1-5?

Studies 1-5 were all monotherapy studies-- specifically, 4 acute trials and one 6 month maintenance study. And all but one acute study worked.(2)

More importantly, two of the trials that worked used 50mg.

In fact, AZ also submitted 5 other studies-- all positive-- to the FDA showing efficacy in GAD at doses starting at 50mg.

So this drug is efficacious as monotherapy in depression and anxiety?

Apparently so, and apparently at doses less than 150. Of course, since the adjunct trials were only done using 150 and 300, those are the doses that get approved. Safety, to the FDA, means they'd rather you get 3x to 6x the necessary dose-- along with a probably irrelevant drug-- than reveal that it worked as monotherapy.

Wait a second-- if there's very little NET inhibition at 150mg, doesn't that probably mean there isn't any at all at 50mg?

Oops.

Why would Astra Zeneca want to convince us that the mechanism of antidepressant effect was NET inhibition, when there is so much evidence (that presumably they are aware of) that it isn't?

Astra Zeneca doesn't want to convince us of that: the FDA does.

----

Coming soon: Part 4

1. Note that 300mg was not better than 150mg. And why would it be? The higher the dose, the more dopamine blockade your getting, which isn't relevant to depression otherwise we'd be augmenting with Haldol, which we aren't. (NB: which is why Abilify augmentation stays below 15mg.)

2. Seroquel 150 vs. Celexa 20 vs. placebo: no difference.

---
http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Taboos Are The Ways Christians Try To Control Us

if I told you the A stood for adulteress, would that turn you off? My husband said the same thing

Of the many emails I received about the taboos post, only a handful were not of the form, "you are a right wing Rush Limbaugh douchebag." Wrong at least two times. You fail.

Here was one of the nicer ones:

So, you're saying to not publicize all your wrong-doings, because there are small pockets of people to support you, no matter what you've done. But, you seem to love Tucker Max (or at least his jokes?) who has basically done that for his ENTIRE life. What gives?

The person who wrote that is a woman in the sciences whom I've emailed a few times, i.e. if she misunderstood the post, it was my fault. So:

So, anywhere you can get support, including the NYT, by all means go. This isn't about getting support, and these individuals aren't getting support. They don't care what you think. That's not what they're doing.

You don't need me to tell you what's right and wrong and anyway I'm hardly an expert on morality. But what I am an expert in is the psychological tricks we play, and their consequences to you. You may be able to live with the consequences, but they exist nonetheless.

Guilt, unlike shame, was always about You vs. Yourself. But what's changed is that You-- the guilty party-- has found a loophole in the system. That loophole hurts everyone.

I.

What did Epstein do wrong? Incest and infidelity.   He did both, right?   What's happened in the press? The incest's severity has completely erased the infidelity. At no time does Epstein have to confront the internal guilt of infidelity, because he's battling an incest charge. I don't mean publicly-- I mean privately, he never faces himself about infidelity, only incest.

Now incest-- terrible, we all agree, but should the law really be monitoring the sex lives of consenting adults? Of course not. "Incest is wrong," I might say, "but we have no business policing it." What just happened there is that "Epstein" has managed to get me to partially support him. I may hate him, but irrelevant- "he" interprets my partial support as part of a global judgment of him, and thus has mitigated his guilt by converting it to shame, and the shame is lessened because some people are partially supportive.

I realize that HE didn't do this on purpose or consciously (though his lawyer is), and HE does not care about my support. But it happened nonetheless. That's the whole point of the media's involvement, our generational solution to the problem of guilt. This is what we will all be doing, the internet as confessional and for the remission of sins. Whether we do it on purpose or not, once a private guilt that (should) gnaw at you gets exposed as a public shame, and the public/whatever newspaper you have at your disposal/your facebook friends/etc start taking sides, that internal guilt is obliterated. Epstein still has to deal with the shame and social and legal repercussions, but not guilt.

What's the result? The result for Epstein isn't my interest, it's his life and it's not my right to keep his guilt alive for him.   But now, FOR SURE, incest is no longer a taboo, it is no longer a matter of guilt, but of shame. Everyone is free to decide whether they can take the shame; everyone has become a Nietzschean superman, deciding for themselves if there are any taboos. Which, of course they were always free to do-- but they had the good sense not to try. Now it is possible to ask "am I free to have consensual sex with my adult daughter?" -- which, of course, you are free to do, and which, of course, you are never free to do. It's that simple.

Do you think it's a coincidence that 2010 had three big adult incest stories, but 2009 had none? They were occurring in 2009, but the gates of that taboo have lost their sentry: guilt. So now incest is a matter of shame, not guilt. If you can take the shame and your daughter's hot, enjoy.

Many in the comments accused me of being an old codger, a "these kids today are immoral" uptight Rush Limbaughlite. If you think that, you're missing something truly important: these aren't kids. These are middle aged professionals who have kids. I expect-- want-- a little Nietzsche in the 20 somethings of the world, to fuel them to do something with their lives. But these are people who should know better. Instead, they've convinced themselves, after 4 decades of life, that they deserve to be happy, that their happiness is more important than anything.

I'm not free of guilt. But the difference is that whatever guilt I have I don't let infect other people. If I am incesting or cheating on my spouse, I would still have the human decency NOT to try and publicly mitigate that guilt by conversion to shame because I know that if I succeed then it becomes okay for someone else. I may have the "right" to do whatever I want, but do I have the right to make it okay for others? How I deal with guilt has an effect on how someone else will. What could I ever say to console my daughter if her husband cheats on her, when I'm in the NYT saying cheating is a matter of "finding a soul mate?"

Every one of our actions has a blast radius, and there are other people in it. KABOOM. Count the bodies.

II.

Would you trust Epstein or Tucker Max to babysit your five year old daughter? It's not an idle question, there will come a day where you will be asked to choose between X or Y and without any kind of architecture to guide you you will choose what my idiot generation has chosen, which is to choose nothing-- "I'm not letting my child out of my sight" and you'll end up like those parents at the park who use their kids as human shields to avoid connecting with any other parent. Result? Your kid doesn't get kidnapped by the Unabomber but he has learned you think all people are evil. Enjoy their adolescence.

"Not a fair comparison, Blackbeard, we're talking about consenting adults. Who would you trust to chaperone your 24 year old wife, Epstein or Tucker Max?" That question is a lie. That question really worries about who would be more successful with your 24 year old wife, and of course that's not a comment on their trustworthiness but on your wife's. If she can't keep some alternative penis out of her vagina then the problem isn't the penises.

But to answer the question, of course I would trust Tucker Max more because I have a sense Max's limits are at X point-- has he slept with all his friends' wives? has he cheated on his wife? (1) -- and David Epstein's limits are only his own physical limitations. Nothing but the law contains Epstein, which is not any kind of containment. If I'm right he does not feel guilt-- that means anything, including eating a baby, is possible. "Are you saying he'd eat a baby?" No. But what's stopping him?

III.

There are a few people commenting who doubt the relevance of guilt, or the need for it; who openly decry it as a tool of the Christians or the establishment as a means of social control. I haven't tracked the IP addresses, but I'd wager big money that those are the same people who want to think Goldman Sachs is evil.

I'd also wager gigantic money that none of these people are carrying around any terrible secrets. None of you supporting Epstein are in the market for adult incest.

What infuriates you is the idea that anyone or anything has control over us. You don't like to be told they aren't allowed to do something. "As long as it doesn't hurt anybody, I should be allowed..." You want complete freedom-- which you will use to conform to very ordinary standards of living that you impose on yourself.

But this isn't a moral issue that I am describing, it is an architectural problem: the very thing that allows you to exist in a world of complete freedom is those internal controls and not the social controls-- laws and shames-- that you think bind you.

Shame will never be enough-- when your identity is "strong" enough nothing shames you, not a sex tape or a prison term, you'll take that scarlet letter and put it on a tight tank top and wear it ironically, not to mention hotly.

The laws will never be stronger than you. Wall Street may need more regulation but it won't reduce the corruption at all. If they want to find a way around the law, they will. Always. The more laws you have, the less relevant guilt becomes.    The laws are exactly the same mechanism as Epstein's shaming: externalizing the rule affords you the opportunity to explore the grey areas. The only thing that will stop corruption is people not wanting to be corrupt.

The new factor is our access to the media, our connectivity. No matter how hard you try, it is impossible to completely block out the judgment of others-- and you won't want to if that judgment is to your benefit.

I am not trying to stop progress or technology, I'm telling you to be careful with your lives. Riddell and Epstein may have dodged huge psychological bullets, but those bullets hit the rest of us right in the face.

---

1. Maybe this isn't the place for a textual analysis of I Hope The Serve Beer In Hell, but he's not so much disrespectful to women as a master of a kind of dialogue with them, one that both of them are completely aware of.

"You're a slut."
"No I'm not! and I'll prove it by sleeping with you."
"Whatever. Let me get my coat."

At least within these kinds of interactions, labeling him "disrespectful" or "sexist" misses the woman's active participation in this kind of dialogue. It's a game, she knows it's a game, she's seen this game before, and she wants to play that game. Interestingly, it's probably correct to say that your missing the woman's active role in the game reveals an implicit assumption of male dominance in social interactions, i.e. you're kind of a sexist.

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===== ====== ===== The Last Psychiatrist: Tech Sunday: Will.I.Am Gets A Job At Intel

taking it to a whole new level

From the press release:

Intel Teams with will.i.am, Black Eyed Peas Front Man

NEWS HIGHLIGHTS

* will.i.am joins Intel as "director of creative innovation."
* Unique collaboration entails the development of new technologies, music and tech advocacy.
* Intel and will.i.am "share a strong interest in innovation around music, art and lifestyle."

For those of you who don't know, Intel is a company that manufactures atomic-scale thinking machines that are the pinnacle of human civilization. I can't hate on a guy who writes songs that make people happy, but his only substantial contribution outside of the world of pop music is punching Perez Hilton in the face. Is that enough on the resume to get a job at Intel?

So why is Intel hiring an idiot to be Creative Director? Because outside of its engineering departments, Intel is staffed and run by idiots. Same goes for nearly every tech company.

The closer you look at the strategic plans of companies like Intel, Microsoft, HP and others, you come to the conclusion that the CEOs of these companies must all be heavy investors in Apple, because none of them do anything that is remotely threatening to Apple. I would like to know how much Apple stock is owned by the guys who run Apple's competitors. It wouldn't be hard to extinguish Apple from the marketplace, Apple's products aren't really that good. Yes, a lot of people buy Apple products. But a lot of people also read The Secret and watch Glee. I wouldn't put a lot of stock in what the masses think.

Apple is successful not because their products are "insanely great." No matter how good they are, their products are obnoxious and way overpriced. $499 for an device with a 1024x768 screen, no ports, no accessible filesystem, graphics from the first Bush Administration, and a 1GHz CPU? That's not overpriced? Yes, yes, we all enjoy the pinching and zooming on the iPad, that multi-touch return-of-the repressed masturbatory ritual that only crudely and temporarily substitutes for real satisfaction. But the thing is so crippled by design you can do nothing with it but consume. Oh, look streaming episodes of Glee. Wicked.

I'm using an iPad last night, and it comes to pass that I need SSH in order to--and I apologize for being technical here--transfer and organize "terabytes" of "warez" and "illegally downloaded Hollywood movies in high definition" among the horrific array of computers on my MPAA-disapproved home network.

SSH is one of maybe a thousand free command line tools that are part of the entirely free Linux operating system. The source code is freely available. All it does is let you log into another machine and get the command line on that machine. So naturally I assume someone has put up SSH for free on the app store, because duh.

I look at the offerings on the App Store. SSH costs $10. Or $1. Or $5. There are about ten different SSHs for sale on the App Store. None of them are free. Most of them have a three-star rating. How the hell does the command line get a three star rating? What is the criticism? "Pfft. This sucks because I can't use Helvetica." Hit the bricks, Hipster, and take your overused homogenized Velveetica with you. It's remote access, you either logged in to the other system or you didn't. It's a binary proposition.

At best, I still have to pay $1. Actually, $1.09 because of sales tax. That's right. Listen up all you 1337 hax0r5 and script kiddies, if you want SSH on the iPad you're going to pay the State for the privilege. How does that sit with your "information wants to be free" ethos?

I think it's unacceptable. It is 2011. I was promised tricorders, Skynet, and flying cars, not sales tax on the bastard child of telnet so that Pixar could crank out movie after movie about baby toys doing baby crap in a way that oddly follows the plot of The Magnificent Seven.

You would think that a competitor would step into this breach to offer a tablet or phone computing device that was, well, a computer. Nope. Oh, I know what you're thinking. You're thinking, "But Android has all the unix tools blah blah blah." You're thinking that because you are a stupid Android consumer who is stupid. Android devices aren't computers either. The flagship Android phone, the Droid X, has about thirty-seven cores running at 1.21 jiggawatts. (Jay-Z is Android's Creative Director). With all that hardware, have you ever tried to run one of those real-time audio apps like they have on the iPhone? You can't. Do you know why? Because Android has exactly the same round-trip audio latency as DOS 2.1. Yes. I looked it up. To do real-time audio, you need under 10ms. Meanwhile, the Droid-What is 350ms in version 2.2 and 45ms in an "optional" package in 2.3. (According to the Davos Summit, "Optional" is an industry term for "Unavailable".)    So, despite the fact that it runs on military-spec hardware, Android can't do the fun multimedia stuff that the iPhone can do (provided that you pay and pay and pay for it (plus sales tax.))

And now Blackberry wants to sell a tablet too. Oh joy. The Blackberry is basically a corporate house-arrest ankle bracelet that prevents you from thinking about anything other than your job no matter where you are in the world. I can't wait for that soul-sucking experience in 9-inch high-definition. With multitouch.

This is not competition. This is copying. Charging users a premium for a locked down OS which in turn nickel-and-dimes the user for single function apps that are freely (and legally) available in much more advanced configurations on normal PCs is not innovation. It's asinine. Which brings me back to the beginning: I'm convinced the CEOs of these other companies secretly hoard Apple stock. How else can you explain this total unwillingness to do the obvious: to bring to the tablet space the computing platform that relegated Apple to a niche player in PCs?

You know what costs $499 and can do real-time audio, SSH, PDFs, Flash, 1080p and
everything else you'd ever what to do for no additional cost? A crappy laptop
from Tiger Direct.

So why don't any of these companies just sell you that laptop, minus the keyboard, with a touchscreen? I would buy that. Today. But no one sells it. Why? Because corporations are amalgamations of people operating in lowest-common-denominator cover-your-ass protected mode. Some corporate sperm donor at Intel or Microsoft or HP wearing khaki pants and a blue dress shirt sees Apple's success with the App Store and decides to copy it in his company. Khaki Blueshirt, VP of Entrenched Thinking, then gets labeled internally as an innovative guy, because in corporate America, innovation means copying Apple without also copying all the artsy designy stuff that is "gay."

Attention corporate America: you don't want to copy Apple. Apple sucks. Yes, they make money. Two-and-a-Half-Men also makes money.   Apple makes money for the same reason Moleskine makes money selling $0.99 cent notebooks for $7.00--because they don't teach checkbook balancing in high school.

I don't need Intel to sell me a quad-core CPU designed by Will.i.Am with two dedicated "urban" cores providing hardware-accelerated Photoshop graffiti tags. I don't need a "krunk" instruction set that invites me to "get retarded."

I need Windows (or Linux, real Linux) in a tablet form so I can download Firefox, Flash 10.1, Greasemonkey, VLC, utorrent, SSH, and a life-goals management app called "Inception 2010 BRRip 1080p x264 AAC - honchorella (Kingdom Release)". That's what I need.

Listen up, Khaki Blueshirt. Just because you upgraded the star wipe in Powerpoint doesn't make you a creative guy. You're a drone. You sell commodity hardware and a lots of it. You want to beat Apple, stick to what you know. Sell tablets that allow users to do more than fingerpaint and view advertising at the same time (yes, there's an App for that.) The hundreds of millions of us that have not bought iPads want tablets that let us do on them what we do on our regular computers--spreadsheets, Powerpoint, movie piracy, and porn. Don't get fancy.

-- pastabagel

---

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===== ====== ===== The Last Psychiatrist: Teenage Girls May Be Having Oral Sex, But The Problem Is You

I sincerely pity the current generation of teens who have to live in a world containing the current generation of adults.

I.

As you are no doubt aware, teenagers today are out of control.

Time Magazine writes in A Teen Twist On Sex,

Americans have plenty of opinions about teenage sexuality. What they don't have are many hard facts.

Funny, I was just thinking that exact thing when I read this article that was free of any hard facts.

They did talk about a study that

finally offered solid data about what real kids are doing at home after school, in the back of the car and between the sheets.

Do tell! (Oh, wait, that's my kid!)

government researchers fanned out across the nation in 2002, surveying 12,571 Americans ages 15 to 44... More than half the adolescents surveyed, for example, said they had engaged in oral sex (and their claims are fairly credible, since the questions were posed not face to face by an adult interviewer but through a specially designed computer program).

Has anyone actually met a teenager? Was anyone ever a teenager, that can remember?

How is this study credible? I get that talking to a live interviewer may make you hesitant about telling him how many guys you've oraled-- yes, that's a word.

But didn't I read in the Panopticon that people are more honest when they think they are being observed? Answering questions in front of the computer skews the answers the other way, it doesn't make you say things that are true, it makes you say things that are true for you.

Teens are narcissists, but this is (usually) completely age appropriate. They try on different identities, figuring out who they are; but they cling tightly to each one, defend it zealously. (Try pointing out to an emo kid he's a white suburbanite whose Dad is an accountant.)

And part of the teen identity is that they are "older than their years." They know more about life, and sex, "than you think I do." A kid may never have even had sex-- but he's imagined it, a lot-- and to a narcissist, imagining is enough. A kid can truly believe he/she is an expert in oral sex-- knows exactly the best way to do it-- even though he/she hasn't ever actually tried it. Because they've "practiced" it a million times...

When the question is, "have you ever performed oral sex?" the answer is going to be yes. And no lie detector is going to disagree, because in his mind, he has.

II.

Here's another idiocy:

it's tempting to theorize, as James Wagoner of the Washington-based nonprofit organization Advocates for Youth does, that the abstinence-only movement hasn't prevented sex but has simply pushed teenagers away from intercourse and toward a practice that for some reason they don't think of as real sex. Says Wagoner: "The abstinence-only chickens are coming home to roost."
You can almost see this nut gloating, another blow to the Bush/Cheney Regime! Though by his own admission kids are avoiding intercourse, hmm, doesn't that count for something? Or should we just go back to penetration?

But in almost the next breath, he admits that there's no way to prove that link or even to say for sure whether oral sex is on the rise.
I see. So it's not clear they are having more oral sex after all? Didn't they do a study on that, which was the point of this article? Perhaps Wagoner should go and read the actual study, instead of wait for his cronies to feed him anti-Bush soundbites?

The article purposely conveys the impression that teens are up to no good, internet style. (What site?) Interestingly, the article failed to mention what are probably the study's most important findings:

...Trend data for males suggest that no large changes in these behaviors have occurred since 1995.

...The findings appear to be similar to previous surveys conducted in the early 1990's.

...These findings are similar to data collected in 1992 by Laumann et al.

Oh. Plus ca change, or something.

III.

But there's a bit of a twist: that article is from 2005, and not obviously so. You get to it by reading the current article The Truth About Teen Girls and it's one of the "Related Articles." So a not at all accurate or informative 2005 article is used reinforce the soundbites and the memes in the mind of the unaware reader, e.g.

...teen girls are getting very liberal with sexual favors, especially of the type detailed in the Starr report. In one generation, girls seem to have moved from Easy-Bake to easy virtue.

Wow, any data on that? Or that the Easy Bake Oven generation was pure? That's certainly not how I remember it.

And as if on cue, the media deliver a new 90210 with an oral-sex scene in the first episode; Gossip Girl comes back with billboards promoting it as MIND-BLOWINGLY INAPPROPRIATE ... and your daughter starts singing that alarmingly suggestive song about licking a lollipop.

What's missing from the discussion about teenagers is the fact that the discussion is being had by adults. That makes this all a discourse-- the vocabulary, the concepts, are specific and convenient for the discussants, not the discussion. They're artificial. And they're completely inaccurate.   You didn't buy it when you were a teenager, and you're not going to be able to sell it now that you're not. Adults see a teenager dress a certain way, and they call it sexy-- but the teen may have an entirely different explanation. One psychologist quoted in the article got it exactly right:

"There's a whole other piece that we don't talk about," says Tolman, "which is holding the people who are reacting to these young girls accountable." When tweens see a picture of Cyrus with her back bare and her hair tousled, they don't see her as postcoital. That's an adult interpretation.
The problem isn't that the kid is too sexy; the problem is that adults are too turned on.

Do you know how many of these singers are into chastity and promise rings-- and yet these are the people accused of being too sexy. Katy Perry's hit song is about kissing a girl-- does that sound like the song of a generation of teens already bored with threeways?

The "sexiness" to them means something different then it does to adults. And something different to adults then it did to previous adults.

When they dress sexy, that might be a different kind of signal to toehr kids that has nothing to do with sex. "Yeah, but adults see it as sexy, and they get the wrong idea." Hmm. Perhaps the problem is with adults?

Here's an example: the article references the "alarmingly suggestive" song about licking a lollipop (which I assume is Lil Wayne's Lollipop.) But kids aren't responding to the sexuality of the song-- check out any message board, they all talk about the rhythm and the beat and the fact that the song isn't really about sex-- not in the way any Motley Crue song is about sex, not in the way Aqua's Lollipop is about sex-- the song is about status. Rich is the new porn. In the video those two guys Lil Wayne is playing poker with, in their house, are the Maloof brothers (owners of the Sacramento Kings, The Palms Hotel, etc.) You think that's an accident? Lil Wayne couldn't find a strip club to film in, so this was a hastily assembled Plan B?

IV.

Adults trying to interpret kids' behaviors using adult concepts often leads to...misunderstandings. But adult narcissists-- for that is exactly what this generation is-- can no more understand "kids today" then the honor killer can understand that he's retarded.

My father's generation liked to remind us how they had nothing to eat but potatoes, walked to school in the snow uphill both ways, dodged Axis soldiers, "but we still shined our shoes every night!" etc. I find it fascinating/nauseating that my generation's version of "the hard old days" is this: "oh my God, when I was a kid, if I started yelling in a toy store like that, my Dad would've beat the crap out of me, right there."   Wow. Just like dodging Axis soldiers. Even stand up comics use it as the segue, "kids are so soft they die if you leave them in the car" and "we need to start beating our kids more!" Why? Look around you. This is the result. Maybe beating kids isn't such a good idea, just based on review of the outcomes.

Further studies are needed, but anecdotal evidence suggests that all of the current problems-- financial disaster, war in Iraq, the need for war in Iraq, 50% divorce rates, increasing racial tensions, worthless college educations, the rise of feudalism-- are not the fault of teenagers, but adults. Though teens are an easy scapegoat, I'll admit.

I am aware that raising teens is hard, and the possibility that some may be performing oral sex. But while it's awesome that we're worrying about the children who are the future of America, we should spend some time worrying about the adults that are its present.

They are, in fact, the ones that suck.

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===== ====== ===== The Last Psychiatrist: Temper Tantrums In The DSM

let me guess

From BoingBoing, only slightly more valid than any of the journals I read:

The American Psychiatric Association is set to add "disruptive mood dysregulation disorder" to the Diagnostic Statistical Manual (DSM), the bible of psychiatric disorders. A kid has "DMDD" if she or he has "severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation... at least three times a week."

Easy, everybody, if you're enraged about the wussification of America you can assume you watch too much TV and like Blue Pills.

1. Diagnosis is not the same as disease. This just coordinates the language, "from now on we're going to call this this." "Then why is it called a disorder?" Ah, you must have no insurance or the best insurance. Healthcare policy is set by Medicaid/Medicare, you Blue Cross suckers are merely collateral damage.

In Medicaid America, i.e. America, if you come through the door and I ask you all the questions and I determine there is absolutely nothing wrong with you, two things will happen at the exact same time: 1. You will punch me. 2. I won't get paid, can't get paid for no diagnosis, no matter how hard I work.

Can't order any tests without a diagnosis code, either.

Someone stupid will ask me this: "then why doesn't Medicaid just offer a billing code for "need three evaluations, but likely no diagnosis?" Because if Fox News got wind that Obama was paying for black people to get "no diagnosis" they'd blow up an abortion clinic. Paying for "temper tantrums" is just the right amount of enraging, TV and internet enraging, no violence will occur. "Isn't this why we need universal healthcare?" Well, lieutenant, pronounced like I'm a British naval commander, if we had a system of healthcare in which doctors were paid the exact same regardless of diagnosis or severity, then there'd be little attention paid to "correct" diagnosis, all of our epidemiological data would be totally invalid, and the number one drug in America would be Xanax. "Wait, isn't that the situation now?" Huh, nailed it.

2. "Is this is an attempt at preventing the erroneous diagnosis of "pediatric bipolar disorder?" No. Come on, stop it. Not to go full Popper, but how can diagnoses be "wrong" while simultaneously "not exist?" You guys have to decide whether you're materialists or idealists, then we can cross blades.

In other words, regardless of what you call it, assuming the MD thinks it is "a problem fit for a pill," will the pills offered be any different in either diagnosis? I'm closing my eyes, don't tell me which diagnosis it is... I'm sensing something, a presence.... is it Concerta? Concerta, is that you? And.... Depakote? Are you here too?

3. "DMDD is "severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation." I'd like someone to explain what behavior is "grossly out of proportion" for a situation characterized by physical/sexual abuse, parental drug abuse, and visibly swarming roaches, every day, while you sleep, while you eat....

"But not all kids are raised in poverty." True, many are raised by nannies who alive in poverty. So what kind of temper tantrum is out of proportion for a situation characterized by marital infidelity/swinging, overparenting, spoiling them materially and depriving them emotionally? "I love my kid, I got him a Wii." You should get them some weed, they'll get it eventually.

"So then it's not really a disorder, it's just caused a response to the social environment?" Isn't that what a psychiatric disorder is? "No, a real disease." Like diabetes?

4. It's all very simple, you have it mostly right but the direction of the force vector is wrong. In order to create a living wage, the system deploys its social services through the least offensive department, healthcare. e.g. people are furious about Social Security, but not as furious about Medicare. As long as it can pretend it's about "health" or "compassion" or "disability" it doesn't have to worry about politics or race or "need".

But in order for this to work, the doctor has to get paid. Not much, but paid. If he is to get paid, the patient must have insurance, i.e Medicaid. In order to get Medicaid, the patient must be temporarily disabled, for which he needs to have a diagnosis, so he must see a doctor, who will need to get paid, so the patient needs to have Medicaid. Ouroboros. The system has won.

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===== ====== ===== The Last Psychiatrist: Ten Extra Seconds Would Have Saved True Detective's Finale

what could it mean?

You just watched a historical TV moment: never before has the audience for a show been smarter than its writer.   I submit as second evidence the season finale for The Bachelor that was on yesterday, for three hours, drawing ten million "people". Just remember that the next time some dummy from The New Yorker complains that TV has a woman problem.

The Whitman's Sampler that was True Detective's finale is beyond discussion, literally, because what we now know is that no discussion was necessary. All the references, all the philosophical subtext, all the weirdness-- turns out it was topping after topping, "does this make you watch? How about this?"     Remember when the one character who turns out to be irrelevant says, "YOU'RE IN CARCOSA NOW," do you know what that meant?   Nothing.    The writer once read a story that had the word Carcosa in it but since his cat was already named Chuckles he used it in a TV script. "It's a reference to--" I know what it's a reference to. Why is it a reference? Does it mean anything? Did "acolyte" or "metapsychotic"?

We see Errol shifting fluidly between several accents. Here is the show I thought I was watching: is this is a 1 Corinthians 14 "speaking in tongues"? Maybe coupled with the aluminum and ash reference it suggests Errol is Baal and Carcosa is Hell?

Here is the show I was actually watching: though not mentioned ever in the show ever, he did that because the accident that caused his scars also made it hard for him to talk in his normal voice.

Meditate on that.

The writer googled Chekhov's Gun, laughed mightily and roared, "you're not the boss of me!" I'm confused, so the killer's ears were green because he painted houses with his ears? The point isn't that this explanation is stupid, the point is he didn't need to have green ears.

I don't care about "tying up loose ends" or sterile Judeo-Christian undercurrents, I have ABC for that. I care only about internal consistency. If you're going to make a show about, for example, zombies that is worth watching, at some point a character must say, "look, the only thing we know with 100% certainty is that every single one of us will eventually but unpredictably become a zombie, so we probably need to devote, oh, I don't know, 100% of our energy to dealing with that certainty." Once you ask that question you are lead, for example, towards a sci-fi show about forced physical isolation where the only contact we have with each other is digital, but because of the lack of physical contact paranoia sets in, and suddenly every interaction becomes an implied Turing Test. Would you watch that show? Because without that question you have four seasons of Denial Lets Us Pretend The Old Rules Still Apply.

A show about applied philosophy in the form of a crime drama sounded intriguing. All of True Detective's existential despair, posed as, "how do you solve a series of murders when humans are a mistake anyway?" -- well? It's finally solved incoherently with an appeal to the Old Testament. Oh, so God exists after all? That would have been helpful to know up front, because I thought we were in Schopenhauer's "time is a flat circle" universe. But whirlwinds are cool, too.

So through some kind of faith, Cohle loses both his nihilism and... his interest in pursuing child killers? "We got ours." Oh, we're done then. Time for a sandwhich.

"I don't sleep, I just dream." Turns out that doesn't mean anything either, but if you're 16 feel free to lay it on the artsy girls. You'll think they'll think you're mysterious.

II.

I'm sure everyone has their own idea of how it should have ended. But as an exercise how could you take the finale that was aired and fix it using only an additional 10 seconds? You can't change anything else.

Could you have kept it true to the show's original promise, such that "pessimist" Cohle is both redeemed AND still true to who he is? Could you have rendered a closing scene so diabolically duplicitous that, on the one hand, most of the characters are saved/happy, while the world's bleak necessity of a tragic hero (since that's all he was, after all) becomes unescapable? That we all live semi-peacefully only because of the sacrifice of a few loners in a garden, coming out one by one to allow their own crucifixion?

"Compassion is ethics." Yes it is. How do you take Nietzsche's nihilism and make it compassionate? Yet not sappy? If you accept that the theme of the show is that life has absolutely no meaning and therefore it is up to you to give it meaning, how do you take the mess that is episode 8 and say that?

Could it be done in ten extra seconds?

At the end they optimistically talk about stars and daughters and life energies, and Marty smiles upon Cohle and Cohle smiles upon the universe, and Marty, having learned the true meaning of Christmas, skips off to go get the car.

Cohle sits alone in the wheelchair, watching him.   The emotion in his face disappears. His face hardens. He takes a long drag from the cigarette.

"But I lied for your salvation."

Cut to black.

Credits.

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===== ====== ===== The Last Psychiatrist: Ten Things Wrong With Medical Journals

I know, right? Only ten?

References

This is how references are done now:

This is madness.
I could make a career out of exposing references that have nothing to do with, or directly contradict, the referenced statement. (Here's one.) This system of referencing makes it very hard to do this-- and I wonder if that's not the point.

It is, by contrast, very easy to link the exact article referenced-- even the exact page in the article. Even Jezebel does this.

Online-- assuming it's not a pdf even though this shouldn't matter-- when you click on the superscript it takes you to the references, which has a further link to the actual article (but not the statement.) Ok-- why the extra step?

Note that the way references are done here is antithetical to science. Look at the reference pictured above. What do you see? What is important? What you see are the authors and the journal, not the scientific content. That's what's implied to be important. We're supposed to accept the science of a statement by the force of the author and journal? But that speaks to my later point about bias.

Subscription
Why should government or Pharma sponsored research require me to pay someone else (the Journal) for access to that information? And why only licensed academics? So, if I'm a welder in Kentucky, I can't know what's really up with Depakote for bipolar? I have to read some nut blogger?

It is a simple process for a Journal to host online all articles as free text. Or, better, scientists can publish their work on their own site (hosted by a university, etc, if necessary.)

Neither are Journals necessary as repositories of vetted information. There are numerous ways these scattered articles can be collated, packaged and even summarized for easy use. Slashdot, Digg, and others are very effective in this regard; and something similar can be done with science. I know, Digg can be gamed. What, Journal of Clinical Psychiatry can't?

Where's The Raw Data?
Rephrasing from above: why am I not allowed to see the raw data from a government sponsored study? (And from Pharma-- if they agree to do a study, then they must agree to make all data public.)
You may have heard that there are rumblings about making this data accessible-- but not to everyone; only to those with appropriate access (academics, etc.) Again-- why?

Slow
This is a common lament, but it misses the point: it is artificially slow. As in on purpose.
Articles that are submitted for peer review should simply be published in a "pending peer review" section. Other sciences already do this. To the criticism that doctors may act on unreviewed science, it should be noted that citing "personal communication" (e.g. an email) as a reference is perfectly acceptable. Is that safer? Oh, and about that peer review:

Peer Review

Even with the most malicious intentions, it would be nearly impossible to create a worse system than peer review.   Peer review does not have the potential for bias; it is specifically designed to retain bias, and to maintain the primacy of subjective opinion over objective findings. The only people who support peer review are other peer reviewers. If necessary, money should be diverted from pediatric AIDS research to help stop to this oligochracy. It's that important.

In medicine, "peer review" is the editor of a journal and three other doctors- that the author suggests as reviewers. While ostensibly the author's identity is unknown to the reviewers, in practice it is simple to determine authorship (type of research; meetings; and even document metadata.) Oh, and the editor knows who you are.
Most people think peer review is some infallible system for evaluating knowledge. It's not. Here's what peer review does not do: it does not try to verify the accuracy of the content. They do not have access to the raw data. They don't re-run the statistical calculations to see if they're correct. They don't look up references to see if they are appropriate/accurate.

So what do they do? They look for study "importance" and "relevance." You know what that means? Nothing. It means four people think the article is important. Imagine the four members of the current Administration "peer reviewing" news stories for the NY Times.
On the force of the recommendation of these three reviewers and the editor-- who, by the way, decides whether to even send it to reviewers at all, or reject it outright-- the article gets published or not. And there is no right to an appeal.
Imagine a movie gets previewed by four people who decide if the movie is important or not, and whether it will play in theatres. You know what you get? Notes On A Scandal, that's what. And riots.

The peer review system also promotes the perpetuation of biases. Doctors are subtly pressed into writing articles about certain topics-- consider the Depakote madness of 2000-2004; the noradrenergic hypothesis of depression in the 70s (where'd that go?); and how every issue of BMJ has an article on war.   (Except July 2008: that was the month they wrote about whether to boycott Israeli academic institutions. Ok.) Academic careers are made, in part, by the number and quality (i.e. journal) of publications, which will be influenced by what they think certain journals would publish. "My research focuses on things my Chairman really likes." Can't wait to read more about evolutionary psychology.

Lack of Debate
There is no way to have a meaningful debate about an article within the Journal system. How do you crowdsource a medical study? As an example: if I find a logical error in an article (e.g. mistaking correlation for causation) I can only point this out by writing a "Letter To The Editor," which, you will be surprised to learn, goes to the editor.
Even if it is published, my Letter will have little attention. But while anyone smart enough can critique a study, only an academic can write the Letter.
It is unnecessary to point out that the rest of the internet-- including news-- works very differently.

Disclosure of Conflict of Interest

Almost completely invalid for its intended purpose.

If a doctor does a promotional program, a "drug talk", he has to disclose the relationship. But if a doctor is dating a drug rep-- that relationship he doesn't need to disclose.

Even more strange is that these are commercial conflicts of interest, only. If you are a communist, or Priest of Scientology, or a serial pedophile; these are not disclosures, even if your article happens to be "Incidence Of Pedophilia Among Communists." Neither is being funded by the NIH (any surprise that NIH studies always find that the generic is the best?) Or being married to the Chair at Harvard. Or having a son on the drug.

Aren't personal beliefs a bias?

To single those out commercial interests as somehow more damaging, more biasing than any others is preposterous. It's not a false sense of security; it's a deliberate misdirection from all the other things that actually bias science. And it sidesteps the entire point of scientific articles-- if they are truly scientific, if the articles were truly "peer reviewed"-- it shouldn't matter what your biases are. I could own Pfizer. The article on Zoloft should be able to stand on its own.

It's worth observing that the peer reviewers are not asked to disclose any of their commercial interests.

Boring
No exposition needed. Either less words or better words.

Abstracts As Promos
See this blog post, where it starts out, "I know, right: only ten?" and then you have to click to get the full article? So my promo has really no useful information in it. You know why? Because I am a blogger, that's why.
Contrast that with the abstract from an important study on Lamictal for maintenance treatment in bipolar (emphasis mine):
Conclusions Both lamotrigine and lithium were superiorto placebo for the prevention of relapse or recurrence of moodepisodes in patients with bipolar I disorder who had recentlyexperienced a manic or hypomanic episode. The results indicatethat lamotrigine is an effective, well-tolerated maintenancetreatment for bipolar disorder, particularly for prophylaxisof depression.
The Conclusions seem to say Lamictal is good for preventing "mood episodes", mania and depression-- is there any other way to interpret it? In fact, this study shows it is only good for preventing depression, not mania at all. Why is it written this way? Because the authors want to advance the idea that Lamictal is a "mood stabilizer" and not what it actually is: an antidepressant.
You have to understand that most doctors do not read the study, they don't even read the abstract-- they skim the abstract.   For this reason, the abstract has to be an accurate summary of the article, not a promo for an idea. But that's why it is written this way; it's not about the findings, it's about the authors' agenda.

What's stupid about this is that negative findings are as important to a clinician as positive findings. They are less important, of course, to academics whose careers depend on positive findings, and the drug companies who sponsor them.
Advertisements
Pick up a medical journal-- inside you will see drug ads.   I haven't heard many people complain that this influences the science in the journals, the way authors' "conflicts of interest" is supposed to. But before you respond, consider that the ads are only for one product per class. For example, in the NEJM, there is a two-page, full color ad for Lipitor, but none for any other cholesterol drug. Oh, my mistake-- there are two, two page ads for Lipitor (running $32,000 per issue). Same with one inhaled insulin; one antidepressant (Effexor); one sleeper (Rozerem) etc, etc. If having ties to Pharma influences the outcome of science, what is the effect of having a financial ties to only one Pharma company per class? (1)

Inflation In Studies
Reducing the value of something by increasing its availability is inflation. This is magnified when the thing in question didn't have much value to begin with. Three strategies:
The same data set, or the same thesis, is reworked into several different articles for different publications. This may seem a benign way to pad your CV, but what it does is fool people into thinking something has more support than it actually does. This is precisely how Depakote became a bipolar colossus.
A topic is investigated multiple times, when even one time was too many.
A finding is described as novel or at least interesting, when it had already been published years earlier by a less "important" researcher.
(nod to Glen for this one)

IF YOU THINK THIS ARTICLE IS USEFUL, PLEASE TWEET, REDDIT, ETC, IT. AND SEND IT TO OTHERS. NOTHING CHANGES WITHOUT MOMENTUM.
-----
1. I wondered if psychiatry journals, having a more limited range (e.g. no insulin ads) would have broader coverage of companies. They did, sort of. Archives, CNS Spectrums, Primary Psychiatry, etc, all had multiple antipsychotic ads (never more than three brands, though) but always only one antidepressant. Not sure what to make of that.

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===== ====== ===== The Last Psychiatrist:

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===== ====== ===== The Last Psychiatrist: Test of Psychopathy 2

no one picks the purple

(Part 1 here)

Each card has a color on one side and an alphanumeric symbol on the other.

Rule: If it is blue on one side, it is a 5 on the other.

Which card(s) do you need to flip over to test the rule?

I had said that most people don't get this question right-- the correct answer is p (blue) and "not q" (G).

However, most people do get the question half right. They mess up the "not q." Almost everyone picks p. And rarely does anyone pick "not p" (purple.)

Enter matching bias: people pick the choices that are actually written in the question, i.e. "blue" and "5." This can be exemplified by rewriting the question:

If it is blue on one side, it is NOT a 5 on the other.

Written this way, people still choose the blue and the 5, because those appear in the question.

Another example:

If it is blue...

is logically the same as

If it is not purple...

But the second way increases the rates of choosing purple, because "purple" is a match.

II.

Does it overwhelm logic? No.

TA= true antecedent (p)
FA= false antecedent (not p)
TC=true consequent (q)
FC= false consequent (not q)

In all of the above examples, the purple card (FA) is wrong. Though it is chosen more often when it matches the question ("if the card is not purple...") it still is the least chosen card by far, because humans are generally good enough at logic to understand that to test the rule, the antecedent has to be true.

III.

So the situation is that people are typically bad at logic, but they are good enough to know that in order for the rule to be tested, p (the antecedent) has to be true.

Matching bias can affect choices, but even that isn't enough to extinguish p as the most commonly chosen answer. They may, or may not, also pick other choices (not p, q, not q, or a combination) but everyone picks p-- especially if it matches the question.

Everyone, that is, except psychopaths.

Review: psychopaths are worse at social contract and precautionary logic than are normals. But what mistake did they make? Did they all choose q? Not choose "not q?"

For that, we'd need access to the raw data. Fortunately, my writing partner, Elisa, is a female, and she was able to email the authors of the study to get the raw data.

And this is what she found:

Descriptives (did not choose p): psychopaths 42%   normals: 34%
Precautions (did not choose p): psychopaths 38%   normals:13%
Social Contract (did not choose p): psychopaths 42% normals: 21%

Psychopaths are remarkably terrible at choosing what should be both the logical choice and the one the matching bias should have nudged them to choose anyway.

You might want to give psychopaths the benefit of the doubt-- maybe they just got overwhelmed by all of the choices?

No; in fact, their version of the test was easier than my version, above. They were shown each card independently, with a leading question:

It seems, well, obvious that if "Helen borrowed the car" there's a chance she could violate the rule by not returning it. The back of that card could say "returned it" or "didn't return it." By contrast, Screen 5 "Dave did not borrow the car" is pointless to choose.

But psychopaths don't see t like that. It seems that they read the question as "SINCE Helen borrowed the car, she is at least halfway honoring the rule"-- so she didn't violate it.

What we are coming to is not a fault in logic, per se, but a different understanding of what a rule is.

Part 3 soon

===== ====== ===== The Last Psychiatrist: Test Of Psychopathy?

you failed

Are you good at logic? Of course not; you're American. No, that's not an insult, it is a description of a process. Follow me.

I.

Each of the cards has a color on one side, and an alphanumeric symbol on the other.

Rule: If it is blue on one side, then it is a 5 on the other side.

Which cards-- the fewest necessary-- do you need to flip to check the rule?

The answer is the blue card and the G card. We'll come back to this.

II.

Each of the colored sides describes whether or not a sweater is borrowed; the other side describes whether it was returned.

Here's the deal: If you borrow my sweater, you must return it.

Which cards-- the fewest necessary-- do you need to flip to check to see if someone broke the deal and has to face the wheel?

III.

In formal logic, this is expressed:

(p then q) implies (not q then not p)

Go through it:

1.

if p then q.
p
therefore q.

2.

if p then q.
not q.
therefore not p.

Many people find formal logic difficult to understand because they read left to right and apply future to the right, past to the left. If/then statements, in language, become about what will happen:

If you shoot him, then he will have a bullet hole in his body (If p then q).

More generally, however, logic is operating in the other direction: what if there is not q?

He does NOT have a bullet hole in his body; therefore, you did NOT shoot him.

P then q also implies: without q existing first, p can never exist.

In any argument if p then q, the only two things you know for sure are: p, therefore q; and not q, therefore not p.

In the cards above, those are the only two cards you need to flip: p (the blue card); and not q (the G or the did not return my sweater). Flipping the 5, for example, is a waste of a flip, it tells you nothing: if it's blue on the other side, then it worked; if it is orange, did that really tell you anything?

IV.

"p then q" represents the form of a proposition, but it can be Englished any way you want:

Descriptions:

If he plays baseball professionally, then he takes steroids.

Precautions:

If you work with HIV patients, then you must wear gloves.

Contracts:

If you borrow my sweater, you must return it.

Don't get tripped up by the words: "hey, it isn't true that baseball players take steroids." "I could borrow the sweater and not return it." This is about the form. If the premise is accepted that "if you are a baseball players you take steroids," can it be true that someone who doesn't take steroids is still a baseball player? No.

IV.

Which brings us to human beings: we suck at formal logic, but, we are excellent at logic as applied to human interactions. Did you do better with the sweater than the numbers?

We instinctively feel the rules of borrowing and returning; and the logic of what happens if "you DON'T return my sweater" (therefore you won't be allowed to borrow more sweaters.) This doesn't mean we don't violate those rules, or cheat; but we understand the rules.

But impersonal descriptions, abstractions (cards, ps and qs) are naturally very difficult for us. Unless you have committed to memory modus ponens and modus tollens and force yourself to rewrite the question in that form, you won't score better than 20% (which is why it is a good idea to do so.)

So if you take a bunch of people who are psychopaths, and compare them to those who are not psychopaths but of equal intelligence:

You see that they do equally well/poorly on the descriptive questions but are comparatively terrible at precautions and social contracts.

From The Economist's summarization of this study:

[The] test suggests that analysing social contracts and analysing risk are what evolutionary psychologists call cognitive modules--bundles of mental adaptations that act like bodily organs in that they are specialised to a particular job. This new result suggests that in psychopaths these modules have been switched off.

That would be one explanation; and if it was the only one, this would hardly be worth reporting in the first place. But there's another explanation.

Part 2 soon.

===== ====== ===== The Last Psychiatrist: Thank God The 'Heart Attack Grill' Is A Great Name; Also, How To Learn French

The Son Of Man will watch over you

Did you hear about the restaurant called "The Heart Attack Grill?"
For the second time in two months, a customer at Las Vegas' Heart Attack Grill collapsed mid-meal and was carted off to a hospital.
Yummy. Here's another:
The Heart Attack Grill in Las Vegas, Nev., has come under scrutiny since one of its patrons suffered an actual heart attack while eating a Triple Bypass Burger there earlier this week.
Or:
(CBS News) Another patron of the Heart Attack Grill has reportedly fallen ill during a meal at the hospital-themed Las Vegas restaurant.
Seems like such a frivolous story couldn't possibly be of any value to anyone. And yet, I'm about to make a mountain out of a molehill. Who wants to see something ugly about themselves?

I.

You might guess that this news story is itself a kind of advertising for the Grill. This cynical view places not just two heart attack victims but all of CBS News at the service of a company's self-promotion. And you'd be right, another branding piece pretending to be a news story.
But we know what the author wants to be true, the question is what you want to be true: how does this story, like all pop-culture and pop-news, represent a wish fulfillment? The story does not exist as information, in fact it is deliberately misleading-- the patron didn't have a heart attack. There is no information there. It is there in order for you to talk about it-- so you have something to talk to others about, through a screen darkly or face to face, because if it weren't for these meaningless media stories which includes all partisan politics people would have nothing to say to each other, and society's collapse into hikikomori narcissism would be total. Which is why it is correct to say that pop culture isn't a symptom of our dying society, it is its heroic measures. So take your medicine: what do you want to say about some dummy who had a heart attack at the Heart Attack Grill?
First interesting observation: the reflex position is to defend the corporation, in the guise of pseudo-libertarianism: "No one forced her to eat there!" and, "no one takes responsibility for their own actions!" and "hey, dummy, how could you go to a place called the Heart Attack Grill and not know you'd have a heart attack, what did you expect?"
This position isn't necessarily wrong, but it is very much a mark of our time that the reflexive emotional position isn't, "those corporate scum shouldn't be allowed to serve that poison, do they feel no responsibility for this?"
Which leads to the second interesting observation: this position is delivered as if it were a minority opinion, full of wisdom, against an uneducated crowd-- as if everyone else blamed the Grill.   And yet a glance at the comments reveals that no one blames the Grill, everyone blames the dummy. The only blame they get is for using the story as marketing.
If you consider how ready we are to blame corporate scum for everything else, giving them immunity to this obvious blame seems paradoxical.
So the question for the individual is, why is it so important to be allowed to eat at the Heart Attack Grill yet accepted that there's a good chance you're going to get exactly what you paid for? I'm going to hide under the bed and wait for your answer. "Is it freedom of choice?" Here's a hint: that's never the answer.

II.
You can run the list of "defense mechanisms" and try to link each one to specific personality disorders, which will help you understand the spouse who left you or the spouse you're never going to leave but the point for now is that what makes them defenses is not that they protect you from pain-- they don't, clearly. They suck at doing this, look around.
The purpose of defense mechanisms is to stop you from changing. So that after the trauma or the break-up or the loss you are still you. More sad/ashamed/impotent/enraged/depressed is fine as long as you're the same guy.
This is what makes treating narcissism particularly difficult: the pathology's Number 1 characteristic is identity preservation. "I want to change." Nope. You want to be happier, sure, more successful, feel love, drink less, but you want to remain you. But that won't work. The identity you've chosen blows, ask anyone. Change is only possible when you say, "I want to stop making everyone cry." The first step isn't admitting you have a problem but identifying precisely how you are a problem for other people. But I'll save you the trouble, you'll fail at this, too, because of the Number 2 characteristic of narcissism: inability to see things from the other's perspective. "This isn't really therapeutic, jerk. You call yourself a psychiatrist?" Mother's Day is Sunday, get her anything? I know, I know, she's a jerk, too.

III.
If you want to watch these invisible unconscious defenses play out right in front of you, in real time, in a real way, watch an adult American try to learn a second language.
Short of cauterizing your own genitals, nothing seems like it would change who you are like speaking in an-other's language. Blech, I'd rather wear someone else's underwear, no thanks, I'll take the 12 credits but no way am I retaining anything. "Well, science says you lose the ability to learn languages as you get older." Oh, did NPR just interview TED?   Dummies in other countries and dummies in the CIA learn as adults, are they all using different science? An American describes another American who is fluent in French as "oh my God, he's so smart, he speaks French and everything" but this statement is easily unmasked as a defense by getting him to describe a Frenchman who speaks English: "well, they all speak English over there." The bilingualism is robbed of the "intelligence" signification because it's seen as customary.... who they are. America is a branded-identity nation, which means hearing yourself speak in not-your accent, with not-your vocabulary sounds very not-you, which is why when an American tries to speak French he feels self-conscious, but the Frenchman hearing it feels you aren't even trying. He'd be wrong, you are trying: trying not to become French.
"Ugh, I hate psychobabble, why can't you be more like Malcolm Gladwell and give me practical neuroscience based tips like 'get up before dawn' or 'play basketball annoyingly'?" Fine, here's your concrete advice that you won't take for shaving 6 months off your second language acquisition: master the accent first. Before even one word of vocabulary. The accent will teach you the rhythm of the words and the grammar-- it will make it okay for you to learn the vocabulary. And you will think differently. American exceptiono-isolationism isn't arrogance, it's a cognitive bias impressed on us from kindergarten when we learn that there are only two languages in the world, English and Everything Else. Which teaches us that a German is more similar to an Italian than a Texan to a New Yorker, and I can predict with 100% accuracy that if that made you pause you only speak English. Can't wait to hear your foreign policy ideas over drinks. You should work for NPR.
Once you have the accent down, pick a foreign language actor or actress you admire, and learn the language as if you were them. Talk like them. This trick works because you are thinking like someone else, acting like someone else, yet simultaneously distancing yourself from this change-- I'm doing this, but it's not me, I'm just pretending. The self-consciousness is removed because it's not "you" who is doing it. Yet it is; and after a time, you'll become it-- and the positive benefit for society is you'll hate the guy you used to be. C'est la vie.
Which brings us back to the Heart Attack Grill. All psychological defenses have a common structure: that two legitimate but contradictory beliefs are held simultaneously, one consciously, one unconsciously, alternating variously. That way all possibilities are covered. Change is neutralized.

IV.

"Hey dummy, what did you expect would happen if you ate at the Heart Attack Grill?"
Why did you expect it? Be careful. It isn't because you knew the food is unhealthy, and I know this because you don't actually know what the food is. You have no idea if a "Triple Bypass Burger" is in any way worse than a Big Mac except that it is branded as worse. If it said "Double Healthy Burger," would you believe that, or does your cynicism only run in one direction? (Let me check the calendar: it only runs in one direction.) "Well, there's a picture of the giant burger right there at the top." Run all you like, Gingerbread Man, I'm still going to catch you. The truth is you assumed the burger was extra-unhealthy as soon as you read the title, before you knew anything else. So why are you trying to pretend otherwise?
Take an alternative headline and meditate: "Man Has Heart Attack At Hooters." Hooters food is poison but there the implication is that the waitresses' boobs were to blame. But the Heart Attack Grill has equally sexy waitresses and no one blames their boobs.
So the expectation is exclusively the result of the names "Hooters" or "Heart Attack" and the connotations they carry. Not the reality-- the connotations of the words. But connotation is the purpose of branding. So "hey dummy, how could you go to the Heart Attack Grill and not know you'd have a heart attack?" reveals our secret hope about branding: that it is true, that it has power to affect reality.
I sense the resistance to this idea. The simple act of naming doesn't give it power, right? The restaurant has to live up to its name. Well, now it has. Still think you should be allowed to eat there?

V.
Is the name 'Heart Attack Grill' meant ironically? The waitstaff are dressed like sexy nurses and doctors, which is meant ironically, i.e. what they provide (fatty food) runs counter to the sartorial expectations. But the name is... not ironic, it's literally correct-- right?
Wrong. The name Heart Attack Grill is ironic, because the expectation is that you won't get a heart attack there, and the reason you know you won't get a heart attack at the Heart Attack Grill is -- and this is where you need to judge the strength of your soul-- exactly that it is called Heart Attack Grill. That's why it is safe to eat there.
This will sound confusing, because if you actually have a heart attack at the Heart Attack Grill, inevitably someone who thinks Kristen Wiig is funny will say: "umm, hel-lo? Mayor McCheese? What did you expect would happen?" Well, not this.... I thought the name was ironic.
God may be dead, but we're not yet ready to shine a flashlight into the abyss to see just how abyssy it is; so we put a distance between ourselves and the dark abyssiness of reality, and by "distance" I mean literally "some other omnipotent entity." And we make that entity exert its power-- prove it has power-- through language. If something is called the Heart Attack Grill, then it could not possibly actually cause heart attacks because no one would ever allow such a thing, any more than they would allow a Vegas brothel called "Syphilis House"-- unless it was actually free of syphilis. The final step is the trickiest to understand but the most natural to execute-- it is the atemporal logic of narcissism, aka magical thinking: the naming of it prevents it from being true. Saying it is ironic is protective.
This is why blaming the dummy is pseudo-libertarianism. It seems that we don't want any restrictions on our freedom, we want to be free to do things even if they are harmful; but that freedom is always predicated on "some other omnipotent entity"'s supervision. We want our freedom to eat unhealthily as long as it is "USDA Grade A" meat from a "Board Of Health" restaurant, cooked not by Mexican illegals with no training in handwashing but by chefs-- sorry, not precise enough: "...cooked by Mexican illegals as long as they are called chefs." We want things to be as regulated as possible with two absolute conditions: 1. there must be symbols of the omnipotent entity's existence showing we are being cared for, like a Grade A seal or the absence of the 13th floor or the word "chefs";   2. the implementation of the power must be invisible so we can disavow it.   And at the very last step of a carefully managed outcome we can bask in the freedom of our pretend choice.    In other words, the fact that we are allowed to choose something dangerous must mean that it isn't really that dangerous, which is more accurately but confusingly translated: the fact that we are allowed to choose something dangerous causes it to be safe. And thank God.   "There is no God." Oh, that explains all the passive voice.

-----

http://twitter.com/thelastpsych

----

Notes:

Two simple examples of this process.

1. In normal people who did not grow up on a farm, drinking milk from a cow will seem more disgusting than drinking it from a milk carton. The explanation will be that it isn't "pasteurized and homogenized," which is both true and simultaneously a lie, because you know milk is dispensed after pasteurization from an industrial vat into a carton

but if you had to pick between drinking from that carton at the supermarket vs. from that industrial vat, you'd still pick the carton. The carton clearly displays symbols of regulation and control, but the vat is too real to drink from.
2. Even if we agree that "taxes are too high" the psychological importance of lowering them is that the regulations that we know to exist will still continue to exist but we are distanced from them; to the point that the person who pays no taxes, or the man who pulls off the grid feels he is no longer affected by those controls; but of course everything he touches is still the result of those forces-- his Cabela's hat and camo jacket are flammability regulated, certain dyes prohibited, factories free of glass shards; all things that he knows are true, but blocks from his consciousness. "I'm totally self-sufficient." Ok. So on the one hand he knows (unconsciously) he enjoys the protection of the regulations, on the other hand knows (consciously) he is entirely free of their influence. This will alternate on the day he e.g. catches fire. This is not a criticism but an explanation: since this disavowal/magical thinking is a narcissistic defense, it's easy to predict that he will have other narcissistic problems, e.g. alcohol, rage, misogyny, etc.
To be clear: what makes this a defense is not that he is wrong, but that he is right, he has a legitimate point-- taxes may indeed be too high, the government too large, too many regulations, etc. If he believed something that was not true he'd be delusional. The defense is effective only if two incompatible truths are held simultaneously, alternating variously depending on what's going on, so that change is neutralized.

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===== ====== ===== The Last Psychiatrist: The 1000 Point Drop and What Is Happening Now

not even close, but that's what the data shows

I. This is What Happened Yesterday:

II. This Is What's Happening Now:

(Jim Cramer) ...Remember, we were down a lot. You cannot have that kind of drop, even if it was exasperated by some sort of computer trading glitch, unless something is really, really wrong in the world, dead wrong in the world. So what is the problem? I have got a theory, it goes like this: governments of the world are uniting in hurting their economies...

No government is ever worried about the stock market. Not in their country, not in our country-- that would be unseemly, beneath their dignity...

Governments worry about three things: paying the bills, keeping people in work, and keeping inflation in check. The issue right now is that these are conflicting goals all over the world.   The areas that generate jobs for other places, especially China and Brazil, they are slamming on the brakes. The areas that are desperate to pay the bills are doing so at the expense of jobs, that is Europe.   And the US, we don't know what we're doing-- other than worrying about punishing the rich people who work at banks. That seems to be a major theme that has captivated Washington.

III. This Is What Happened A While Ago:

Why was Galileo persecuted by the Church for saying what the Church had previously paid Copernicus to say?

Copernicus was afraid to publish On The Revolution of Celestial Orbs not because he thought the Church would stone him, but because he was afraid other academics would laugh at him. What was threatened was the Aristotelian paradigm.

A hundred years later, the paradigm was much more... flexible. It could accommodate new data supporting an old theory.

Oddly, Galileo's own data technically showed that the Earth didn't move-- the Sun revolved around it-- but that the rest of the planets revolved around the Sun. But Galileo was seeing his data through another (Copernican) paradigm, so he... interpreted things differently.

Galileo had an epic scientific debate right under his nose that would have kept everyone occupied for hours. The Church would never have been involved. But Galileo wasn't satisfied with science; he wasn't satisfied with showing that Ptolemy was wrong, nor was he worried that he might be showing Copernicus was wrong-- he wanted his data to be evidence that Catholicism was wrong, e.g that Scriptures had to be interpreted figuratively.

Galileo broke the Cardinal Rule: wovon man nicht sprechen kann, daruber muss man schweigen.

IV. Repeated, for emphasis:

...Remember, we were down a lot. You cannot have that kind of drop, even if it was exasperated by some sort of computer trading glitch, unless something is really, really wrong in the world, dead wrong in the world.

===== ====== ===== The Last Psychiatrist: The Abusive Boyfriend

not pictured

He doesn't hit you, he's not that kind of abusive.

And he's not mean, or controlling, not like that. No, not really.

But he's careful to make sure you don't notice that a certain movie is on tonight, and he's deftly avoided ballroom dancing lessons with you. And he walks you the other way if he spots one of your friends, or any billboard with Gabriel Aubry on it.

He's not jealous, he just doesn't want you... distracted.

He has no problem admitting that other men are attractive ("I'm no Tom Cruise"), but never the men that you yourself find attractive.

He's never mean or disrespectful to your friends when you're out together (he goes reluctantly, but for you), but later he reminds you of how you're better than they are, and when they do things "like that" it's silly/wrong/beneath you. He never says you can't go out with them, but there's always a coincidental reason for you not to. "Oh..... well..................... I had a special night planned for just the two of us..."

How sweet he is, once a month he buys you a new CD, classical music, with a flower, though now you don't really listen much to the music you used to like.

He is always with you, always in contact with you. Even when he's not there you hear him in your head like a voice over. You've even said to him, "sometimes I'm about to do something that I would have done before I met you, and then I hear your voice and I think, "well, Tom would say XYZ" and I realize that I shouldn't do it after all, and I feel so much happier having that part of you with me" and he nods knowingly, yes, he says silently, you're learning to be a better person.

No one else who knows you understands why you're with him.

But you're not unhappy. When you're with him, alone, things are usually great. And he loves you, there's no question. Maybe you think he's worried you don't love him? But you do, how can you express that to him, so he believes it, so he doesn't have to feel threatened by anyone else?

Save your breath, that's not what he's worried about. He has a different class of dread, because he is, after all, really smart, and perceptive. He has, deep down, that feeling that you're not really compatible, and he may even know he's not good for you-- he may suspect he's actively clipping your wings so you don't get away.

He tells himself that he's keeping bad influences away from you, protecting you from "your old self." But he doesn't completely believe that-- he is,after all, perceptive-- he secretly knows these "bad" things are better for you, they are more you. He knows you'd be happier with them. But then there'd be no room left for him.

What's he sure about is that this is the best there is. Other things, different things, may make you temporarily happier; more money, a trip, more freedom, a bigger dick, laughs with friends, but in terms of your life, your soul, this is as far as you need to go.

He will help you pursue any goal, any happiness, as long as it does not compromise your relationship with him. He will give you everything and allow you to do anything, as long as nothing makes you wonder if he isn't manipulating you, as long as nothing makes you wonder if another kind of life is possible. Not a better life, just a different life. He'll take a bullet for you on instinct, but if another man innocuously tells you he's also interested in art history or compliments your hair, then you'll relentlessly over months be presented with subtle reasons why art history is a fraud and you need a haircut. Attacking the man would be too transparent.

But why so much energy controlling the world? Why not just let things be and see what happens? Is he so afraid things will get worse?

No. He's afraid things will get worse or they will get better. He is afraid of change, any change, not just because the relationship may change but because if it changes then he would have to change. Into what? How? With what resources? With what net? Once change has happened, doesn't that mean other possibilities were obliterated? It is his possibilities he is trying to beat down with your sclerosed dreams.

All that matters is keeping the relationship intact. Even if you both end up miserable, better misery and stability with him than the tachycardia of something else, something unknown, something he can't control or defend against.

Do you know this guy? You think you do.

This is what you need to know: the boyfriend I'm describing isn't Tom, the hipster who's number one on your speed dial. And no, I'm not directing this at you, man-boy, I'm not saying you are doing this to your woman, though you may be. At any moment there is only one person in the room no matter how many people are in the room, and that one person, you, is lugging around the same man you've lived with for years. The abusive boyfriend I'm describing is your unconscious, and Tom has nothing on him, though Tom has, through the hypertrophied intuition of damaged men, figured out how it all works.

The unconscious doesn't care about happiness, or sadness, or gifts, or bullets. It has one single goal, protect the ego, protect status quo. Do not change and you will not die. It will allow you to go to college across the country to escape your parents, but turn up the volume of their pre-recorded soundbites when you get there. It will trick you into thinking you're making a huge life change, moving to this new city or marrying that great guy, even as everyone else around you can see what you can't, that Boulder is exactly like Oakland and he is just like the last guys. And all the missed opportunities-- maybe I shouldn't, and isn't that high? and he probably already has a girlfriend, and I can't change careers at 44, and 3 months for the first 3/4 and going on ten years for the last fourth, and do I really deserve this?-- all of that is maintenance of the status quo, the ego.

You think you're with Tom by accident? You were set up.

And when all else fails, it will beat you down with apathy. Or the Monday night lineup. Or pot. Or-------------------

The men, or women, aren't lying to you, and you're not even lying to yourself. You are being lied to, by yourself.

===== ====== ===== The Last Psychiatrist: The Action Movie Fairy Tale

The woman asks, why won't my man have sex with me?

I.

80s and 90s action movies were often maligned not just for their violence, but also for their lack of depth and psychological sophistication. "They're not important."

But these movies built a generation of men who are now in their 30s and 40s.

They didn't learn that killing is cool, which was the worry of people who didn't watch those movies and didn't understand. This violence was central to the cinematic experience, but incidental to the story.

The complainers ignored the story because they thought it was basic, trivial. Wrong. Write down the plot synopsis of every action movie, and awareness will come over you:

A marginal guy must save a hot chick from bad guys; when he does, he gets the girl

II.

A generation of adolescent boys learned immediately three things:

1. marginal guys are the real heroes.
2. heroes never die.
3. bad guys exist as bad guys, not as good guys who went bad, or bad guys with some good in them also. Darth Vader was unquestionably bad starting in 1977, unimaginable that he was once a sweet young boy with good in his heart. That story had to wait a whole generation to be told.
4. in order to get (active verb: to obtain, procure, convince) a hot woman to fall passionately in love with you, you have to do do some extraordinary things: take out thirty terrorists, master kung fu, be in the special forces, etc.

III.

Focus on #4. The question for today is, why do men have trouble having sex with the women that they are committed to? Why does it seem that women have higher sex drives than men?

This is not a complaint I recall hearing in the 1970s or 80s.

Start with: there's something eerily adolescent about men today.

The movies say: until you do something extraordinary, or "save" the girl, then the love you feel isn't true love.   Women may be the ones looking to feel "explosions" inside telling them they're in true love, but men externalize those explosions in to real explosions before they know it's love.

How did you meet? Was it a good story? Did it involve defying the odds or secrecy? You'll make it. Did you meet in a coffeehouse or a bar? Then you're dating your future ex-fiance(e).

The male libido falls not because he's not interested in the woman he's with, but because he's not interested in the movie he's in.

Women say: you're wrong, it's porn, it's TV and magazines and airbrushing and implants and impossible figures...

Nope. Consider that the serial monogamous relationships of these guys are with women who are actually quite attractive. Other men want them. If the guy's friends knew she wanted sex more than he did, they'd knife him. And it's not boredom, either-- what, is masturbation so exciting?

For a man in a committed relationship, the porn is a distraction, not an ends. They're not looking at porn to get off, they're avoiding sex. Actual sex is exposure. It reveals that he is not the fantasy man he thought he was. He'd be a better lover if he was.   Ha. And women thought it was that they (the women) didn't measure up to the fantasies. As an aside: jealousy is directly proportional to sexual desire in these men. That's not advice, just an observation.

The men love their girlfriends/wives, and are loved, but there's the feeling that it's not "real," she's not "the one." Women have fantasies about what a relationship is like; men what a beginning is like.

A few points: first, for men, love is tied with a sense of accomplishment. They can't imagine a woman would really want them if they weren't accomplished, so when a woman is interested, they think it's not the real thing. Everything is a stepping stone. But accomplishment isn't what makes him "good enough for her." It's not even to entice her. It's not for her at all. It's acquiring the pieces to his identity, like a Star Wars collection. Success-- check. Money-- check. Woman-- check.

This man goes through the motions of love: he is present, he doesn't cheat-- he doesn't even have the motivation for that!-- he is warm, loving, dutiful, respectful--

but he isn't there, he is always elsewhere, he has the thousand yard stare of someone who is expecting, any moment, his real life to come marching through the tree line.

IV.

"But then you are saying that the problem for these men isn't sexual attraction or commitment issues, but a psychological inability to love another person?"

What other person? How can you love a person who doesn't actually exist?

V.

"I think I'm one of those people, how can I change?"

You don't have to change, you look away from the pool.

VI.

It's similar to the complaints about fairy tales and girls: rigid gender roles and depictions of false success. And now women are waiting for a white knight to sweep them off their feet.

Well, I don't know any women who feel this way, they learned quickly that those stories are only beginnings-- what happens next? An example is the movie that wrecked a decade of young women in the 80s: 9 1/2 weeks. 20 years later, I still have yet to meet one woman who saw it and obtained the message, "be careful of charming men, they may seem great in the beginning but.." Instead, women connected with it, wanted it, they'd describe their own relationship like Rourke/Basinger's, proudly, they sought it out, they'd create it. What they wanted about it was the passion, "I wish a man were that into me!" What they learned from that movie is that in order to have a relationship as passionate as that one, with a guy as good looking and successful as him, you have to lose part of yourself, do things you don't really want to do.

Ah, but she left him at then end. Wrong. He'll be a part of her forever. That's really what he wanted-- do you think he wanted to be with her when she turned 60? Do you think she'd want him if she were 60? She wants to know she was worth that much passion.

Too many women learned the wrong message, not that they should wait for a white knight, but that keeping a white knight may involve a heavy cost. And they paid it, with abusive 80s and bicurious 90s, whatever it took.

VII.

The action movie was not about glorifying violence. It was a manual: how to get an identity, how to get people to like you.

You disagree. Twenty years of media studies and postmodernism says I'm wrong, "the action movie is catharsis through contradiction: death brings life; bad is good. The action movie is says the hero must become antihero, take on all the bad, become bad, so that good can be saved and no one else has to be bad."

Well, reality says I'm right. Ask: what would happen if a man saved the hostages by taking out out thirty terrorists in a LA skyscraper in real life? He'd end up interviewed on TV, he'd get a makeover, and he'd get a million dollar book/TV deal. In short, he would be rewarded. The money and the interviews mean: you finally see me for who I always knew I was.

This is a possible explanation for why depression and suicide is so high among combat vets today. They fight a battle and then-- nothing. They only get on TV if they do something wrong. "I did all this, and I get nothing?"   One of the only 80s action movies that didn't have a damsel in distress was First Blood, in which Rambo, who actually was a Green Beret, came back to the world only to find that not only did no one reward his identity, they hated him for it. But even that was a sort of confirmation. You don't need a girl when enough people hate you for who you are.

VIII.

The 80s adolescent hits the 90s full force, then 2000, and with every passing year it becomes more certain he will not learn kung fu or join the special forces. Now what? How is he supposed to find true love if he was never in the special forces?

Answer: go find a girl who was in the special forces.

Just in time for the first midlife crisis, Hollywood has our back: Alias, Underworld, Lara Croft, etc. You think we like those women because they are sexy? Then why wasn't Pamela Anderson's Barbed Wire the ultra-popular? Was Jennifer Garner a Playmate? It has nothing to do with sex, it is all about love. The movies say: my reality is becoming increasingly limited by my uncooperative body. It's probably impossible that I can take out thirty terrorists and save the girl. But it's slightly less impossible that I could meet a woman who could do it. Phew.

IX.

But at some point, a man has to grow up, and this is where it gets interesting. At some point you realize the action movie isn't going to happen in real life. You're going to have to confront reality, have to meet a girl and fall in love with her for real, and try to be happy, and know that you don't get to try on several different wives to find one you like. Nor do you get to keep trying on identities. You're going to have to face life as an accountant or a product manager, and not as a CIA agent, or music producer, or pro-ball player-- all of which are the exact same thing. Then what? Three choices:

1. alcoholism and depression, especially the subtle variety called ennui
2. accepting reality and finding one's place
3. the schizotypal condition

The one to focus on is #3. What modern middle aged narcissist wants is to find a way to put one foot in reality, and keep one foot in fantasy. A solution that lets him keep fighting the traffic twice a day without blowing his brains out. To have just enough hope that one day the fantasies could come true that he keeps on going. That a 30 year old man could suddenly know kung fu.

Fortunately, we find ourselves at the tenth anniversary of just such a solution.

Part 2 here.

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===== ====== ===== The Last Psychiatrist: The APA Says The Media Is Making Women Really Hot

So the APA has come out against the sexualization of women in the media. Praise Jesus. And not a moment too soon.
Oh my God. If society could just expand it's historical horizon past winter, we'd realize that women have been sexualized for centuries. It's only in modern times that women are allowed to be in control of it.
No. I'm not worried about girls, What we should be worried about are the boys. What happens to a boy who is told by the media that women are sexualized, they are objects, they are sluts? And then he goes out into the world and discovers they aren't? That they won't sleep with him? That, try as he might, they won't do all the things he was promised in ads, movies, porn? But they might be willing to do it with someone else, even women?
Depression? Or maybe misogyny? And maybe he starts hating women so much he, oh, I don't know, shoots 30 people at a college?
Women have been tweezing and preening and primping since day uno. Near as I can tell, porn hasn't drastically altered this. Interestingly, it has made young men more self-conscious, not just about penis size, but also body hair, fat, fingernails, etc. The cultural problem is neurotic, immasculated men whose only outlet is masturbation and violence.
Are we going to be honest or political? I don't know any women who if given a choice would prefer "not sexy" over "sexy." If I have a daughter, I would want her to be in control of her sexuality, not under the control of it (in other words, the opposite of me.) I want her to be smart and sexy. I just want her to be her.
No. No, the problem isn't my daughter becomes a slut; it's that she gets beaten by some whacko who wants her to be. Or doesn't want her to be. Or does, but only when...
The real problem for the women of our society isn't a lack of self-esteem. It's a lack of weapons.
And no, I'm not kidding.

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===== ====== ===== The Last Psychiatrist: The Atlantic Recommends Abandoning Marriage Because One Of Its Writers Can't Keep It In Her Pants
It's easy to criticize, harder to explain.

Read the article here.

Or, read the article with explanatory notes to the text.

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===== ====== ===== The Last Psychiatrist: The Best Way To Improve Your Creativity

Moving only three circles, make the overall triangle point downward.

Spend a few minutes on it before reading the hint.

Hint: this is part of a psych test developed by University of Texas students enrolled in a study abroad program in China.

Scientific American has an article An Easy Way To Increase Creativity, which describes the recent paper about the effects of psychological distance on creativity.

The SciAm article is worth reading. Students were asked a series of brain teaser questions. One group of students was told that the questions were invented at their university; the other group was told they were invented in a far away university. Thinking that the test came from far away somehow raised the creativity of the subjects. They answered more questions correctly.

But in this paper, the researchers told the subjects that there was a psychological distance involved. How would you do this to yourself?

One way would be to imagine the question came from far away, or form another time. Another way would be to imagine you were far away from where you are now (e.g. answering while on a vacation in Hawaii).

But I'm going to illustrate another way-- the way I personally use on complicated problems and in writing a lot of the posts in this blog.

II.

Answer this question as fast as you can:

Name ten animals.
Note carefully your answer. Most likely, your first 6 or so answers are of one category of animal (e.g. farm), and the remaining ones are from another category of animal (e.g. zoo animals).

Even dementia patients can name a lot of animals-- "cow, pig, horse, sheep, umm, cow, no wait, ummm...." but what the demented can't do well is switch to another category. They get stuck in the same box, looking around in there for more answers. They don't lack fluency, they lack flexibility.

So knowing the answer to "name 300 animals" isn't about knowing 300 animals, it is about knowing 30 categories of animal, and being able to jump from one to another.

Imagine you are on your 200th animal, and now you are stuck-- you can't even think of any new categories.

Creativity advice is often of the form, "look at it a different way." Ok, but I don't even know what way to look at it to start trying for a new kind of solution.

Here's my trick: imagine you are someone else answering the question.

Who that someone else is depends a lot on what you're trying to do. Sometimes I pick a person related to question (e.g. The Crocodile Hunter guy); sometimes I pick a guy unrelated but clever person (e.g. Stewie from Family Guy). It can't be a generalization of a person ("how would a biologist answer?") it has to be a real person that I know enough about to model their thinking, but different enough from me that alternative answers are possible. But I don't linger, I don't force the guy to answer if he can't; I cycle through multiple identities to get quick looks at the problem. (Why this method works is explained a little more fully here.)

A prisoner was attempting to escape from a tower. He found a rope in his cell that was half as long enough to permit him to reach the ground safely. He divided the rope in half, tied the two parts together, and escaped. How could he have done this?
This question is from the paper, and I couldn't answer it-- but Jack Bauer did. Silly, I guess, on some level, but I chose a guy who would know how to escape from towers, and the solution then came almost immediately.   It's more than just "what would Jack do?" It's about being that other person, what would I do if I was him-- I imagined myself harried and relentless, pausing only to say "dammit!" I need to get her out of here, and I need to get her out now--

so I frantically split the rope lengthwise, tie the ends together and to the window, grab her by the waist, and jump--------

II Addendum/clarification:

(some have commented that splitting the rope wouldn't hold a person. Others commented that "getting in someone's head" is BS.)

The idea isn't to think, "what would Jack Bauer do?" It is to think, "what would I do if I was Jack Bauer" because the goal isn't to get out of a tower, it is to answer a brain teaser.

Trying to think like you as Jack Bauer allows your own mind to have one more method of thinking, it adds a new road. Taking yourself out of the process, "what would Jack do?" limits your thinking, it limits it only to the mind of Jack Bauer.

For example: Jack Bauer himself wouldn't split the rope and tie both ends, because Jack Bauer knows this wouldn't work, because he knows ropes. I don't. But allowing myself his brain gives me abilities to think of things and in ways I wouldn't previously.

Again, the point is to boost my creativity, to help my brain to think with additional software, not to replace the existing software.

And you only do it for moments at a time. If thinking like Jack Bauer failed-- after a few seconds, because I'm really looking only for flashes of inspiration-- then I would have moved on to another person.

III.

Note also that my inclination is towards psychology; another person might be able to establish creative reference points by translating the question into a different language, or imagining it printed in different color, or font; or answering it using thinking from different eras, etc.

But effective methods of adopting psychological distance or alternative perspectives have two important similarities. They are predicated on the idea that who you are, and how your mind works, can be artificially altered at will-- you can actually think thoughts you were neither biologically nor environmentally primed to think; and they establish that an inability to see things from another perspective is almost always a failure of will, not of intellect.

----

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: The Black Swan Movie Review Criminal Attorneys And Hollywood Don't Want You To Read

already seen it

I was once involved with a woman and we decided to stay in and watch a movie, she was a professional cheerleader who was interested in dancing, travel and working out, and the movie I chose was Pi.

45 minutes into one of the best movies I had ever seen she says, "I have absolutely no idea what's going on in this movie. All I see is a paranoid fucker living in a world of madness."

II.

As I was leaving the White Trash Monday (matinee) showing of Black Swan, exactly what I predicted to myself would happen happened: a woman turns to her boyfriend and mentions how beautiful the Swan Lake ballet's music was, and how she'd like to get it from itunes.

Is it beautiful? I'm no expert on beauty, pornography is more my thing, but I'll go with yes. But I do know that that woman is in for a surprise, what she heard in the movie wasn't the music of Swan Lake but the same 4 measures of Swan Lake Act 2 looped over and over and over and over again, like it's being played by a wind up music box, which half of the time it was.

Those of you musically inclined will observe that I erased the F clef and edited out the first measure (four beat rest) to generate the above graphic, which is analogous to what the movie does: exerts considerable effort to spoon/force feed you the necessary elements, when letting them happen naturally, which would have been easier and more rewarding.

That's just the music. Now imagine what it does with the psychosis.

III.

Are there any new stories in the world? A high school girlfriend told me the universe was made of them. I'm ok with remakes, but you have to take the story somewhere different, right?

Here's the story: Nina is a dancer and wants, then gets, the top spot in Swan Lake. The previous prima ballerina got old. Nina is an innocent, childlike waif. The director knows she'll be great as the white swan, but can she tap into the dark side to play the black swan? In so doing, she goes crazy, has anorexia, eats a cake, has bulimia, skin picks, kills herself, maybe kills someone else, has sex with Mila Kunis, punches her mom, takes ecstasy, never once mentions the existence of a father, and turns into a bird. I'll leave you to sort out the order.

In parallel: Natalie Portman (the actress) loses a ton of weight, many times thought she would die, thinks what will get men to want to see an Aranofsky film is a lesbian scene, and marries her costar. No, the other guy.

Sort of parallel: Mila Kunis (the actress) denies getting drunk before the sex scene, and ends a 9 year relationship with the kid from Home Alone. (So that's what happened to him.)

We get to see her crazy ex-ballerina mom infantilize and control her, and her French director try to seduce and mature her. There's the psychological tug-of-war: the mother wants to keep her as a child, the director wants her to become a woman, Nina can't choose so she District 9s into a bird.

The problem with this interplay is twofold.

First, the porn-- doing the most obvious to generate the desired emotion. The mom isn't just Carrie crazy, she is exactly Carrie crazy. The French director isn't just smarmy, he is exactly "French director" smarmy. Example: he grabs her crotch and whispers, "respond to my touch. Respond to it."

As advertised, there's a lesbian scene in the movie, it's supposed to depict the psychosexual component to Natalie's obsessiveness. Mila Kunis and Natalie Portman get naked, and Mila lustily gives Natalie
oral, and I'm thinking to myself, what's the matter with me that this terribly unsexy? Am I too old? Too much porn?

The literary answer, the subtext answer, the one that is never touched, is that perhaps Nina's relationship with her mother is not just controlling but incestuous, a ha!, which explains why Nina would dare to have her first lesbian experience at home, in her princess bed, with her Carrie mom banging outside the door; Mila Kunis becomes a projection of mother who brings a guilt ridden Nina to orgasm.   The only way she can orgasm is with mom; and the only way she can orgasm is to pretend it's not mom. And when Nina is masturbating on her princess bed, at the moment she should have an orgasm she (thinks she) sees her mom asleep in the chair. Sex without mom is impossible; sex with mom has made all other sex impossible.

That's one answer. The other answer is that I've already seen this scene, this exact scene, a dozen times. No attempt is made to make it different, unique to this story, important to this story. Hence, it is gratuitous; and I certainly have no problem with girl on girl gratuity but when it's done boringly even I will be bored.

Secondly, it's wrong. When those two forces pull, they pull at angles with a resultant vector, they are not exact opposites-- you don't get torn apart. If you go with the psychoanalysts, the schizophrenogenic mother causes psychosis through certain interactions, but explicitly NOT because there's another force in your life opposing the mother's. The alternate force, however bad it was, since it opposed mom would be reality grounding, and while you can still get every kind of personality disorder and a lifetime of messed up relationships, having that opposing force prevents psychosis, not enhances it.

Natalie Portman adeptly plays lots of different pathologies: anorexia, psychosis, OCPD, etc-- but these things don't all manifest in the same person and certainly not because of events in your life-- this thing made me OCD and this thing made me hallucinate and this thing...

It is also the kind of crazy defendants fake when they want to pretend they're crazy. Not understanding real psychosis, nor the specifics of the legal term "insanity" often means defendants endorse or exhibit every symptom I throw at them. They pull a Nina, thinking I'll be impressed. (A very common one: cross modal hallucinations, e.g. seeing and hearing a demon talk to you, are rare in schizophrenia and if they actually happen are usually the result of drugs or other organic illness.)

Of course, anything is possible and blah blah, but since this depiction is not novel and not accurate, what is it, and why is it at least partially effective? The answer is that it's a genre piece. The genre isn't ballet, the genre is paranoid fucker living in a world of madness. Nina's craziness is the (male) audience's fantasy of crazy, it is a template for the kind of crazy a 20something wants to pretend he has to impress girls. The crazy part is a signal to girls: I'm passionate, creative, driven. (FYI: It almost always signals a lack of commitment.)

The movie is very much what an outsider assumes happens in a world he doesn't inhabit. Crazy overbearing ballet mom? Seems plausible. But doesn't exist-- not at the professional level. That's grade and high school stuff. A person who needs to work hard at a profession would have abandoned such a mother (fathers are different) long ago because it interfered with her own progress. Crazy soccer mom? Check. Crazy Olympic soccer moms? No. Where you would see such an enmeshed mother-adult daughter relationship, with the mom living through the daughter, is when there is no technical skill necessary, e.g. living through their daughter's beauty, youth, relationships. I don't expect pathological enmeshment between Natalie Portman and her mom; it wouldn't surprise me in Kim Kardashian.

IV.

None of this is to detract from Natalie Portman's Christian Baling the role or Aranofsky's tremendous directing and emotional impact (Ron Bennington: "Aranofsky's movies make you hate the human body.") But the story doesn't do anything but repeat scenes from other movies which were better in their originals. This is why Natalie Portman could probably get an Oscar for Best Actress, but the movie isn't a contender for Best Picture. Nine years married to Rachel Weisz, he's going to be predisposed to melodrama.

Unfortunately, where I see Hollywood headed isn't more sequels or more remakes, but more copying, more cheating. When a movie copies a scene from another movie, that used to represent an allusion; it now represents a cheat sheet to the audience: remember how you felt about the dance scene in Jacob's Ladder, the fear, sexuality, confusion? Just apply all that here, it saves me the work of exposition.

Here's an example: the preview before Black Swan was for a super cool movie that I really want to see right up to the part that it turns out to be a Transformer.

But listen to the music. At the big reveal, the music they play is the Lost crescendo; and at 1:45, the way they signal we're not in Kansas and things are not what they seem is to play the Inception theme.

And on and on. The Adjustment Bureau is a Matt Damon movie about fate. So when you want to quickly create a backstory, just put the Fringe guys in anachronistic 1940s clothing and Dark City yourself a spiral staircase

and we'll take it from there. It is in all ways identical to the shortcuts and cheat sheets we employ for ourselves-- branding-- to generate a backstory without having to put in the work. "See this hat? It means I like to think about the things I heard on NPR."

I'll still go see these movies, of course, but I find myself wishing someone would do something original or at least in an original way. By all means, make it 3D.

---

You might also enjoy:

Surveillance Movie Review

Wanted Movie Review

===== ====== ===== The Last Psychiatrist: The Boy Who Cried Wolf
2600 years ago a fable was written, read by generations, understood by none.

The boy cried, Wolf! and the villagers came, but there was no wolf. And the boy laughed, amused with himself and by their gullibility. He did it a second time with the same results; and a third time, each time to him more amusing.

But the next time was not a joke, a wolf indeed came, and killed most of the flock, and almost killed him. Wolf! Wolf! But no one came, of course. It was too many times.

Even when a liar tells the truth, they are never believed.

II.

The winter came, and the villagers were cold and hungry, and many died, for there were no sheep. An old man from another village shook his head: why was such an important aspect of their survival trusted to a boy? How much did you expect from a child?

He seemed really mature, observed one man. And we're really just children ourselves. We didn't notice much of a difference.

Why continue to leave him in place after the first lie? Or the second? Clearly he doesn't take the job seriously. If you no longer trusted his call, why did you leave him there? "But we were busy with other things."

Perhaps you knew wolves were coming, inevitably; there was no stopping them. And rather than try and fail, you didn't want to be the one blamed.

Or perhaps you expected that because he lied about the wolf, that there was no such thing as wolves. Not: he lied because there are no wolves. Since he lied, therefore there are no wolves.

Other than the solitary boy you left in the field to do a job you didn't trust him to do, what other warning signals were you expecting?

The boy grew up, resentful at the villagers' resentment towards him, what did he do wrong? He called them and they did not come.   They told him they would.   They lied. And like the children they are, they took no responsibility-- they tried to blame him.

The adults in the village failed, the blame is theirs entirely. Wolves exist, you don't throw a boy to the wolves. And when you send a boy to do a man's job but still treat him like a boy, then the problem isn't the boy, the problem is you.

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===== ====== ===== The Last Psychiatrist: The Boy Who Learned To Talk Too Late And Too Fast

I.

This is the story of a boy, he just turned four, but he couldn't talk yet- nothing more than one or two words at a time, "mik" and "mo Nemo!" and that was it. The worry was that there was something wrong with him, and everyone who discussed it never said the word Asperger's.

There are a million reasons he could have this speech delay, including but not limited to genetics, increased paternal age, thiomersal, elevated serotonin, or parts of any of those, but for certain it could not possibly be related to being bookended by an cooing pork sausage of a baby brother and a preposterously hyperverbal, parentified 5 year old sister. and a father who was angry all the time because the junior partner is an idiot.

But at least mommy was for him, she got him, she was tender and strong and consistent and available, a brick wall between him and schizophrenia.

II.

I ask him to come here, but instead he goes over to a box of animals and looks for a rhino and a leopard. He doesn't have a transitional object, he has a transitional object of the day, supremely important on Wednesday and then Thursday dropped like a candy wrapper. Today it's a leopard. Yesterday it was a metal spatula. I don't know.

"Come here for a second."

He blinks. "Lepar." That's 4 months of speech therapy.

"I know, but come here for one second first."

"Lemmmddd." He's not paying attention to me.

"Stop, for one second, just come here--"

"Lepp lleppp lle. Hmmwp!"

"Listen to me! just come here, you can get that later--"

And then God touches him and he says:

"No, Daddy, you have to wait a minute, I'm doing something right now."

BLAM!    I am blown away by the complexity and maturity of it-- that's not even his voice-- and simultaneously furious that he would talk like that to me, that the first coherent sentence he puts together is used to blow me off.

I almost explode.

Almost.

III.

It sounds indignant, disrespectful, but that's not his intention.

He sees people can talk, and when they do they control things. So the only thing standing between him and domination of his environment are words. Words aren't for communicating, they're for effecting.   Words are power. You don't even have to know what they mean. They're magic spells.

The words don't matter, he doesn't even understand them, for him it's all prosody, the way people wrongly say "I could care less" or "for all intensive purposes" or a quote in Latin, they know what it means but not what it literally means, the literally part is irrelevant, because they're communicating something else that everyone gets. He figures that surely I'll get it because he's heard me use those exact words before, and when I used them it worked.

He's not telling me, he's conjuring, he thinks that sentence will change reality, cause it to be true that he is allowed to find the leopard. In the same way he hears my words "come here for a second" not as a request but as a omniscient description of the future: "in moments you will be compelled to do something that you will not like."

III.

But I'm too angry to figure this out, I'm too angry to see things his way, I see them only my way, this is why when they emptily say, "I'll bet you're a great father" I say "as long as my wife is alive."

He sees the rage and frustration in my face. He starts to cry, my boy, my little boy that I love. The boy that is now confused- he used words, and they failed-- they backfired--

He tried; I failed.

At this moment I still don't get it but by instinct I know I'm wrong somewhere, so I hug him, I tell him I'm very sorry I yelled at him and that I will help him get the leopard, but buddy I wasn't saying you can't have it, you can, "come here for a second" just means you come, I do one thing very fast, then you go. Not many things, just ONE thing. And buddy? That was very, very excellent talking, I LOVE it when you talk like that, and we're going to talk about benkenobi's lightsaber is blue and parasaurolophus and pirates.

He grins, my mystical boy, he has a leopard in one hand and a rhino in the other and he puts them both in my face and roars excitedly, and I think as long as I can stay out of his way, he'll be great.

------------------

related: AM Radio Kids

------

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: The British Model Of Cost Effectiveness Fails On Philosophy
Good idea, sort of, but it misses a key element.

The NYT has an article which, for some reason, is entitled "The Evidence Gap."

The British National Institute for Health and Clinical Excellence (NICE) uses evidence based methods to determine whether a drug is worth the cost. Th example they site in the article is a new kidney cancer drug that costs 3 to 4 times more than NICE has budgeted for that disease state. NICE uses quality adjusted life year to determine a treatment's merit, and then weighs it against the cost. According to the article, it's about $20k per six months of life.

Ia. What Price Life?

Certainly people are outraged; life is worth any price. Unfortunately, no one seems to have the courage to say this, use it as a first principle. Instead, NICE says this:

Equity lies at the heart of the NHS. Lack of equity... was one of the reasons why NICE was established. Much of the philosophical literature on equity is far from being applicable to the real world.¹⁸^,19 NICE has therefore had to make its own judgments.

Yet another group of doctors who believe they are living at The End Of History. Whenever I hear, "this time it's different" or "the old way of thinking doesn't apply" I know to expect the opposite to occur.

Ib. What Price Life?

But the argument over "what price life" is a red herring, the real question is "who best to decide how to allocate resources? and the answer (IMHO) is not government, but doctors.

The main support for the government plan is that it lowers drug costs. First, by restricting the use of certain meds, and second (from the NYT:)

Drug and device makers, which once routinely denounced the British for questioning product prices, have begun quietly slashing prices in Britain to gain NICE's coveted approval, especially because other nations are following the institute's lead.

Aha. Pharma voluntarily lowers prices to be able to fit within the government's budget. How much more effective would this be if they had to cut it to fit within the doctor's "patient budget" by which doctors are told there's a certain amount they can spend

Additionally, creating a budget for doctors will force Pharma to start creating drugs that fit into the budget. So either the cost will come down, or they'll create something that's worth the cost.

But what about those patients who need more than their budget? Simply allow a "prior authorization" system by which a doctor can call the insurer/Medicair to expand the budget, and he can cite his reasons. Oh, it's a pain? That's the point. If it is really worth it, it will be worth it. And make it so the doctor can even bill for the time. The obstacle alone will greatly reduce "impulse buying" of meds ("I wanna try Pristiq!") Consider that simply having a discussion with a reviewer-doctor alone is worth the government's effort, because there are docs who never get a chance to talk to anyone except a rep about what's going on in medicine. Hell, offer CME credit for the discussion.

II. What Price Autonomy?

But why not let the government control the budget? What advantage is there in giving it to the doctors?

Autonomy. Doctors don't want to be dictated to by government. Since we must unfortunately have some sort of control plan, give as much control to the doctors as possible. Consider that if medicine becomes so flow-charted, so controlled from the outside, then smart people will not be interested in becoming doctors.
Education. If they have to decide what's worth it, they'll have to stay current. Even if the flow-chart tells you exactly what to do next, do you really want a doctor who doesn't have a full understanding of the issues?
Alternatives. Doctors may actually try to use non-pharmacologic treatments. The horror! I have a question: if diet can lead to bad health, why can't a good diet lead to not just neutral, but better health? Why can't a food be as good for you as some are bad for you? e.g. if Big Macs are bad for your cholesterol, what foods would lower cholesterol? Doctors are not trained to think that way anymore.
The government is not a doctor. Neither are the people in NICE or any other body that determines cost-effectiveness. Oh, I know they're MDs, but they're not "on the ground" doctors. Their focus is not reality based.
Corruption. If a doctor is "corrupted" by Pharma (or his own academic interests, or political bias, etc) then that's one. If NICE/FDA gets corrupted by Pharma (or their own academic interests, or political bias) then that's the game. If you want to see what top down bias looks like, it looks like Depakote.

III. What Price Dignity?

British authorities, after a storm of protest, are reconsidering their decision on the cancer drug and others.

So we see that when the drug deals with acute survival, there is controversy. Ok, Perhaps the model shouldn't be applied to those drugs, at least not at first. But it most certainly can be applied to psychiatry, for which there is no evidentiary, logical, or even anecdotal reason to think that any one medicine is necessary at any cost-- hell, at even double the cost. (I'd grant you lithium and clozapine, but they're already generic.)

I know, I know, "doctors already have too much to worry about, they can't be busy with drug costs." Too bad. Seriously: too the hell bad. The current system is untenable, something must change. If you don't like this plan, then you will have a government plan. See II, above.

The budget needs to go to the doctors; and then doctors need to get together and start learning again. Set up advisory panels, put the academics to work on something real, instead of silly clinical trials which are biased-- not just by Pharma, but by their own desire for advancement. "I believe in antiepileptics." Awesome.

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===== ====== ===== The Last Psychiatrist: The Bubble In Academic Research
And history is quite clear on this: once a bubble pops, it never reflates.

From Science:

A controversial policy requiring researchers to make their papers freely available to the public at a U.S. National Institutes of Health (NIH) Web site is facing a potential roadblock. Last week, members of a powerful House committee held the first-ever congressional hearing on the policy and floated a proposal to overturn it.
Breathe. Think about this. NIH sponsored research was supposed to be freely available in an open access format (PubMed Central), under the intricate logic that if taxpayers funded it, they should be able to read it. But

Law professor Ralph Oman of George Washington University in Washington, D.C., argued that NIH's policy is a "dilution of the rights of the copyright owners" and "will destroy the commercial market" for science and technology journals.
Well, duh. That's obvious, and by obvious I mean, of course, a red herring.

Don't make the mistake of thinking this has anything to do with maintaining a journal's revenue stream. They certainly didn't complain when Pharma sponsored studies had to have their data open access. So why would they care about NIH open access?

Apparently, it costs a journal $4000 per article to publish it, at 50% gross margins. I have no idea where that money goes-- the authors get nothing for writing the article, and peer reviewers get nothing for reading them-- but that's enough reason to destroy this unnecessary system.

The mistake is thinking that open access is a threat to a journal. The trickis: subscriptions are paid by big buyers (e.g. universities), and they don't get to choose what they are subscribing to. You buy the Elsevier Package, and you get whatever crap journals they happen to be offering. Say you want only American Journal of Obstetrics and Gynecology- $600/year. Too bad-- it's coupled to Brain Research, at $23,000/year. I defy anyone to disagree that there has never been, and never will be, a finding in Brain Research worth $23,000.

Universities will pay whatever it costs to get the crap journals in which their NIH sponsored research is published, even if they also have to buy the other crap journals.

Open access articles isn't nearly as big a threat to publishers as simply unbundling the journals from each other, letting universities decide which ones to buy.

So open access doesn't threaten subscription revenues, it threatens the number of journals they can publish. It's the multitude of journals, each with its inflated subscription rate, that brings in the real money. Also, each crap journal carries advertisements; even a crap journal with a small niche can have higher ad rates because of the bundling.

Elsevier alone made $3B in revenue last year. That's a lot of business to be at risk, by science.

II.

But wait: this is a bill blocking the block the open access policy of the NIH that was put in place last year. Why weren't researchers putting their stuff up on the internet before that, anyway? Just for fun?

Why didn't each lab simply create a website and reprint everything? It would take no work-- I assume they didn't write out their findings longhand with a quill. It is technically a violation of copyright, but have you ever heard of a journal coming after the author of a paper for violating copyright? Me neither.

The answer is that a lot of the payoff of research is the publication itself. Where it gets published often matters much more to the researcher than what was actually discovered. Research is often conducted with a journal in mind and "what's hot" in a field--- as decided by the members of the editorial board of the journal, who decide based on their particular interests (read: funding streams and prejudices.)   BTW, these are often the same guys who are grant reviewers. This almost completely drives decisions "on the ground" on what to study and what not to study. (Or did science sufficiently crack the mysteries of lithium to warrant a complete move to Depakote?)

Would anything in AJP be worth reading if it wasn't actually in AJP?

If you think about it, the entire past 15 years in psychiatry have produced no discoveries at all. None. We have different medicines, okay; but they're not better, just different. We don't have a better handle on the anatomic or genetic or anything causes of anything-- we're not even any further along in defining our terms. Thousands of articles rehashing the same old ground have kept thousands of academics employed, to no benefit whatsoever for mankind.

Take away the journals and the system collapses. Force researchers with NIH grants to publish their findings without the marketing and packaging of a journal, and you've effectively halted half of the NIH research, until another generation of researchers with a different research model show up for work. For sure, unquestionably, you've killed off psychiatry as it functions today.

The academic research system is flawed because it does not incentivize research, it incentivizes the process of research.

Academic research is a bubble, money keeps flowing into it as long as it produces quality research. Who decides quality? Journals are the rating agencies, Moody's, they keep it sustainable by giving it AAA rating. The ratings agencies are precisely what keeps the bubble inflated, just like with the mortgages, they are what keeps research money pouring into the system.

If someone could look behind the ratings, and take measure of the actual value of the research, the bubble would pop faster than, well, you get the idea. Then there's the "systemic risk."   Journals collapse, academic centers collapse from lack of funding, Pharma loses the AAA rating on their studies which are done by academics, published in journals, etc.

Research would be forced to change completely-- and for the better. But you'll have a decade or so recession in science and education while the old generation dies out and the new one becomes old enough to start work.

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===== ====== ===== The Last Psychiatrist: The Charade is Revealed-- We Are Doomed

Here's a question: can an antipsychotic be an antidepressant? Why, or why not?
The correct answer is that the question is invalid, because there is no such thing as an "antipsychotic" or an "antidepressant." We (should) define them based on what they do, not what they are. Therefore, Wellbutrin and Effexor are both antidepressants if and only if they both treat depression-- not because of some element of their pharmacologies, which are anyway different. Strattera, on the other hand-- which has a pharmacology (in some ways) similar to Effexor-- is not an antidepressant, only because it doesn't treat depression.
Following, just because something is called an antidepressant, or antihypertensive, it doesn't necessarily take on all the other properties or side effects of the others in its "class." Not all "antidepressants" have withdrawal syndromes (only SSRIs do). Not all antihypertensives cause urination (only diuretics do.) You wouldn't dare put a "class labeling" on "antihypertensives" of "diuresis."
So you see where I'm going with this-- except you don't.
I've previously yelled about the inanity of "antipsychotic induced diabetes" or "antidepressant induced mania" when they ignore pharmacologies, doses, and, of course, actual data.
But today I saw something that I now understand to be one of the signs of the Apocalypse. It is the new package insert of Seroquel, which just got a new indication for the treatment of bipolar depression. The new PI reads:

Suicidality in children and adolescents - antidepressants increased the risk of suicidal thinking and behavior (4% vs 2% for placebo) in short-term studies of 9 antidepressant drugs in children and adolescents with major depressive disorder and other psychiatric disorders. Patients started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. SEROQUEL® is not approved for use in pediatric patients. (see Boxed Warning)

Stating the obvious: in none of these 9 studies was any patient actually ever on Seroquel; Seroquel itself is not associated with a risk of suicide; it's not even been tested for major depressive disorder; and, well, this isn't very rigorous science, is it?
Just because a is now called an antidepressant, it carries the same risk as the SSRIs? (Whether even SSRIs have this risk is besides the point.) Isn't that, well, racist?
This is not really about preventing suicide. If we were worried about suicide, really, then why 24 hours before the FDA posted this warning, no one cared about Seroquel's doubling of the suicide rate? Oh, because it doesn't actually double the suicide rate? Die.
So the game is clearly not about science, it's about politics, it's about liability, it's about money.
If this was honestly about about protecting children from suicide, we'd shrug our shoulders and say, "well, they're just very, very cautious, so we'll be careful and keep going." But that's not what this is. What this is factually inaccurate, misleading, and therefore more dangerous, more harmful. In a simple example, this warning protects no one for a risk of suicide-- no potentially suicidal patient is going to look at this and say, "well, crap, I'm not taking this." But it may prevent someone from taking it when they could actually benefit. See?
This is Structuralism gone very badly awry, Saussure just bought a pick axe and he's come looking for us all.

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===== ====== ===== The Last Psychiatrist: The Chart Is Dead, Long Live The Chart

I. In the Annals of Emergency Medicine appears a short article called, The Chart Is Dead- Long Live The Chart.

The article explains how the chart has regressed from a place to write down thoughts and ideas ("writing as thinking") to a fee extraction device, simply templates specific to reimbursement guidelines, and not the delivering of care. This means that the chart does not aid in the work of the clinician; I'd add that it actually becomes the work. The chart is dead.

Summarizing some of the author's, and my own, observations:

Default terms and ideas which go/don't go into the chart-- so all charts look pretty much the same. There is barely anything in the record that distinguishes one patient from another.   It's as if privacy laws are superfluous.
Unreliability of the information. On day 3 of a hospitalization, does "+SI" mean he really had SI, or is that just there for the insurance?   Does PERRLA mean P+E+R+R+L+A, or just "Patient had two Ps?" This isn't a comment on clinical rigor. Let's assume doctors are doing a thorough job regardless of documentation. The question here is that since PERRLA doesn't actually mean P+E+R+R+L+A, why document it at all? Who are we really trying to fool?
Research by retrospective chart review is therefore invalid. It is unreliable, misleading, and worse than useless. Please read that 100 times.
The shadow chart-- and any resident will know exactly what this means. "Sign outs" or "the list," three lines long per patient but substantially more focused and useful than the entire actual chart. Often, information is there that would never dare be included in the regular record: "mother likely borderline as well." Lawyers have no idea what they're missing out on; and, here's a secret-- the sign outs are usually typed on the same ward computer. Let fly the subpoenas.
Since doctors believe the chart to be a billing form or evidence in a malpractice case, they are not using it as a diary of clinical care. The irony, of course, is that both insurance companies and lawyers pretend that it still is the very thing that they have caused it not to be.

II. How did it come to this?

Another article in the Annals of Internal Medicine, entitled "The misinformation era: The fall of the medical record" also criticizes the uselessness and unreliability of the chart. The author observes that clinicians are often afraid to document things that might upset the patient:

Physicians have become cautious of writing that a patient is paranoid, flirtatious, hypochondriacal, verbose, or homosexual. Possible demeaning comments about the patient's manner, dress, speech, level of education, and intelligence are also omitted.
If flow-chart medicine is what we strive to practice, than let's imply dispense with charts-- and doctors-- fire up the Hippocratobot, and start billing Medicare. Otherwise we're going to need to accept that, in order to be effective, a doctor is going to need to know even the things which are "irrelevant," precisely because they are not. And he's even going to need to write them down somewhere.

The rest of the article will resonate with any clinician:

In view of the flagging integrity of medical record information, it is particularly galling that medical records have been accorded such authority in our society. Physicians may spend as much time with records as with patients. Medical records dictate whether and how much physicians and hospitals are paid... Records determine our patients' insurability, job qualifications, credit ratings, disability awards, and retirement. They are central in malpractice litigation...

...But to restore the integrity of the medical record is more difficult. The manipulation of chart information physicians go through to protect private information about patients from public view and to satisfy the cost-control regulations are demoralizing and degrading to medical professionalism. This subterfuge will continue until confidentiality is restored to medical records and the regulations are revised to accord with the realities of practice, rather than requiring clinical medicine to be a mechanistic clockwork technology. In the meantime, all medical record information should be regarded as suspect; much of it is fiction.
Boy, things are getting worse. Actually, no: this article was written 20 years ago.

III. So if things have been this bad for a while, what is the real problem?

The charts haven't gotten worse, our ability to think has gotten worse, the chart now simply reflects that. I know we believe we chart differently than we practice or think, but the two are very connected; what you write causes you to think a certain way. Since we are not writing down dating history, therefore we are not thinking about dating history, it becomes secondary. We're instead thinking about about "mixed episodes." Get it? We're trying to reduce "dating history" into a symptom cluster.    What's on our minds first is Lipitor and LDL, and only secondarily quit smoking and eat better, because we document Lipitor and cholesterol, our charts contain places to write those down.

"But isn't LDL important?" See? You've been contaminated also. The number is meaningless beyond low, normal, and high; and those three have relevance only as they correlate to other pathologies. But you have information bias, you feel like you need to know the actual number, you feel like it tells you something, you feel like "normal" isn't informative enough. And I'm telling you "normal" is more informative because your mind is not cluttered with the uselessness of "one hundred and nineteen."

Knowing that certain info should go into the chart (Lipitor) causes you to think about that primarily.

The second problem is this: the doctor is required to do two entirely contradictory things. First, he is supposed to do what he thinks is best for the patient. Second, he is asked to document the facts of his prosecution.

No one looks bad if they don't write, "told to eat carrots." But you look sloppy if you write ""LDL high."

In other words, the medical chart is a college application: here's what I did, to the best of my embellishment, knowing that you don't care about what I actually did, but rather about the things you think are important-- all of which I did only because that's what you want from me. Can I get paid/dismissed now?

IV. You're kidding, right?

No. Maryland State Board of Physicians v. Eist, 2007.

A man-- not a patient-- complains to the Medical Board that Dr. Eist overmedicated his wife and son (Eist's actual patients), which caused (supposedly) his wife to become psychotic and the boy extremely anxious.

The Board, trying to get to the bottom of it all, told Eist, and I'm quoting,

deliver immediately upon service of process a copy of all medical records of [the wife and son]; treated at your facility; which materials are in your custody, possession or control.

His response was, and I'm paraphrasing,

bite me.

Slow down, Souter, Eist is right: the complaint was filed by the husband-- he's not the patient; and he was in the process of divorcing his wife and demanding custody of the kids. Get it? No? Once the Board gets the records, the man would then be able to demand those records from the Board as evidence for his custody hearing: "my wife isn't fit to care for her kids."

Well, the wife eventually allowed Eist to release the records to the Board, so he did. In thanks, the Board slapped him with a $5000 fine for not having complied immediately.

V.

What do you think Eist wrote in that chart that he didn't want the husband to see that-- and this is important-- the husband couldn't have obtained from other sources? The husband has empty prescription bottles in the house; he has insurance bills. He knows she went to a shrink. Do you think Eist was doing dream work with her, and documenting it? Of course not.

The state board, in its brief to the Court of Appeals, argues that the lower courts failed to weigh appropriately the state's need for patient records when investigating alleged medical misconduct and the doctor's ethical requirement to preserve patient confidentiality. The records sought from Eist concerned primarily the drugs and dosages prescribed by the physician, data which medical agencies routinely collect as part of their compelling interest in protecting the health of all residents who seek medical care, the board states.

The Board itself expected there'd be nothing useful in the record.

Eist's, and all doctors', dilemma is this: if he has written what he really wants to write in the chart, and the husband gets hold of it, he's damaged his patient and can even be sued for doing so. So he shouldn't give the Board the records. On the other hand, he's punished for not giving the records-- because the Board expects that he/you are smart enough not to put anything in those records, so why wouldn't you give them up?

So then why would he/you write something in the chart that, if it fell into the wrong hands, could damage your patient? You wouldn't. Are we supposed to honor the confidentiality of medical records but assume they can be read by anyone at any time? Apparently yes.

VI.

Doctors have to document for billing and for malpractice, but at the same time not so much that it would damage the patient in the event of accidental disclosure. If these are the things on his mind as he is writing the chart, it is impossible for these things not to be on his mind as he practices medicine. To the exclusion of other things. It's not just that it takes up time; it completely changes the way you think.

Example: They'll write in a progress note, "Lipitor 10mg PO qd." But they'll write that information also in the section called "Medication Record" and also photocopy the prescription. But no doctor would ever write only "Lipitor" in the progress note, because that seems incomplete. Try it, see how weird it feels. Is triple documentation useful? No. But it triply reinforces that that information is very, very important, while things you don't write down-- "needs to eat two carrots a day and one less donut" is less important.

How we chart makes us worse doctors.

VII. "It maybe makes you a worse doctor, but you're a jerk anyway. I'm not like that."

Let's all agree that I am not a person short on thoughts. But I notice in my own practice that I don't think about things which are later obvious to me when I'm listening to music not writing in a chart, because my pattern is to write certain things down.

Life is one big Stroop test. Don't read the words-- just say out loud the colors you see:

It is very hard to attend to what you think is important when you are faced with competing informaion. Note that the only way to really succeed at this task is to avoid reading the words.

These are just stupid colors and words. Do you really think you can block the effect of thrice documented Lipitor in your practice?

VII. What's coming?

Easy answer that no one will like. Since it is evident that chart serves no useful purpose to the clinician; and it only serves a negative, or limiting purpose vis a vis insurance and litigation, and it adversely affects the way we think about patients and the way we treat them, it will, inevitably, be abandoned. What will replace it? The only thing that is objective enough to serve both science, billing, and forensics:   video.

Which is another reason why I am retiring.

===== ====== ===== The Last Psychiatrist: The CIA Has The Same Problem Medicine Does

After some dozen years' immersion in intelligence, I still find myself reacting uncomfortably to its rather cavalier disregard for the footnote.

Both the CIA and medicine have little patience for regular reexaminations of primary sources.

("Footnote" to the CIA does not mean that referencing a journal or book, but refers rather to the actual source (guy) of the information, when, where, under what conditions, etc. In this way, footnote is more analogous to individual data points.)

John Alexander (not his real name) writing in the CIA journal Studies In Intelligence, A Modest Proposal for a Revolution in Intelligence Doctrine:

For example, and I find this quite ironic, the higher the level of the intelligence product, the less complete is its visible documentation. In other words, the more serious its import and the closer it is to the influential official who will act upon it, the slighter is its overt back-up.

At the lowest level, of course, is the raw intelligence report. This report is generally extraordinarily well evaluated and supported. No scholar could really, within the normal limits of national security, ask much more....The user of this kind of report can easily and effectively apply the canons of evidence in evaluating and testing the information.

As in medicine-- at the lowest level we have the data driven studies, and that data is right there, available to all. The Methods and Procedures are carefully described.

But as we move up the ladder of intelligence reports the documentation gets sparser. The NIS (National Intelligence Summary), to use a well-known example, is in effect a scholarly monograph, digesting a great multitude of raw reports. Its total documentation usually consists of a single, very brief paragraph commenting on the general adequacy of the source material.

And then we have a review article. While the studies reviewed are referenced, the data in those studies is not rehashed. With statements like, "in this well designed trial..." we are left hoping the author actually read the article he is referencing, and critically examined its data, and didn't just cut and past from the abstract.

Next up the ladder is our analogous "Expert Guidelines:"

At the more exalted level of the NIE (National Intelligence Estimate), documentation even in the generalized form of comments on sources has usually disappeared altogether. One is forced to rely on the shadings given to "possibly," "probably," and "likely" and on other verbal devices for clues as to the quantity and quality of the basic source data. These examples from the NIS and NIE are paralleled in a great many other publications of similar refinement. One may admire the exquisite nuances and marvel at what a burden of knowledge and implicit validation the compressed language of a finished "appreciation" can be forced to carry, but one cannot help being concerned about the conclusions. Upon what foundations do those clever statements rest?
One can only speculate.

II.

It's going to be obvious to some that rehashing the primary data points, over and over, all the way up to the "exalted level" of treatment guidelines is going to be impractical. What we need to do is trust that the intermediary authors and experts are doing it. No one expects Bush to look at the sat images himself; but perhaps Tenet should. etc. Well, there's a problem with this as well:

Another situation that troubles me is the vast array of editors and reviewers ...to which an intelligence product is subjected before it is finally approved for publication.... I recognize that many of these reviewers are highly talented, experienced individuals....But what basis do they have for their exalted "substantive" review?

Translation:

these reviewers have not generally been systematically exposed to the current take of raw data. Their knowledge of current intelligence events is based on hurried reading of generalized intelligence reports or on sporadic attendance at selected briefings. They are not aware in any particular instance--nor should they be--in any real detail of the material actually available on a particular subject.

Medicine's experts rarely have much recent experience "on the ground." They don't treat raw patients (as opposed to clinical trial patients); their knowledge of other people's studies is no more complete or penetrating than anyone else's-- but because they are experts in their field, they are able to put their imprint on other people's work. The three idiots who review a paper on, say, Zyprexa induced diabetes, are experts in psychosis, but none of them have more than intern level training in diabetes or in structural pharmacology. This is why there are so many "experts" talking about diabetes, but none have told us why it occurs.

And so, once a paper fits the bias of the peer reviewers, what actually happens in peer review?

As a result much high-level review... has consisted of the discovery of occasional typographical errors, small inconsistencies in numbers cited in different paragraphs...
The author notes that even this flawed system has worked surprisingly well; and there are fields of medicine about which the same can be said (surgery); but the reason it works there is because there is a real and visible consequence. Were you wrong? People die.

Psychiatry isn't like that; you can be wrong for decades and no one notices. People die, certainly, but no one sees the link back to the practice. Couple that with the-- academic nepotism?-- or at minimum groupthink which is the formal and explicit basis of all psychiatric practice, and it becomes evident that something has to change.

But nothing will. This CIA article was written in 1964.

Related articles:

Ten Things Wrong With Medical Journals

What's Wrong With Research In Psychiatry?

Are Drug Companies Hiding Negative Studies?

-----

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===== ====== ===== The Last Psychiatrist: The Cognitive Kill Switch

this interview is about me, but it's for you

Convoluted story not worth exploring, Carrie Prejean, Miss USA contestant, was involved in some kind of litigation with the Miss USA pageant in which a masturbation tape she made years ago/yesterday figures prominently/not at all, resulting in some kind of settlement, and culminating with an appearance on Larry King to promote a book.

King asked about the terms of the settlement; she said he was "being inappropriate." He asked if she could say why she settled, and she said "Larry, you're being inappropriate again." She said "inappropriate" four or five times more before she pulled off her mic and left.

A "nobody" shut down pro-interviewer Larry King. When a woman uses that word on a man, the conversation is over, whether he is right or wrong. The man is on the defensive, the whole conversation changes, it's no longer about the thing that was inappropriate, it becomes about the character of the kind of man who would be inappropriate. He spends the rest of the time trying to defend himself, and, of course, she never has to answer the question.

Cognitive kill switches change the focus from content to identity. Popularly, this mechanism is referred to as "short circuiting", but "kill switch" is better because it implies it's deliberate.

II.

One thought is that this works because of a power imbalance. If she was in a bar, where the power is mostly equal, she wouldn't say "inappropriate," she'd say, "die." But with Larry King, or in an situation that does not have an escape (e.g. work, an airplane-- a place where some relation must be maintained) she could reverse the power imbalance by calling him "inappropriate." The only thing he can do is back off, which of course was the point.

But there are too many exceptions for it to be just about power. It wouldn't work on a psychoanalyst in therapy; he'd simply reply, "tell me more about that." It wouldn't work on a rock star. Larry King caved, but I can't imagine Howard Stern caving.

What those men on their side is an established reputation, identity: "you think that was inappropriate? Do you have any idea how inappropriate I can get?" Which translates as a willingness to confront the person about their use of manipulation.   It's a kill switch, too: she changes the focus from the content to his character, but then he changes the focus from his character to hers. He wins because his identity is already established.

So "inappropriate" fails because the guy is known, and what was "inappropriate" actually wasn't inappropriate coming from him. And, in the reverse: kill switches works when they are at least partially right.

Prejean is correct: King was being inappropriate. He may have said "settlement" but Prejean understood he meant "sex tape."

She realized that King didn't care about her, only about the sex tape. The only reason he asked that question is to get to the sex tape. She's not a full person to him, she's a news story. Now, you can say she's an idiot for thinking there is any other reason to interview her, but regardless she thinks she's much more interesting than just that. From her perspective, he is a man who only cares about her because she is currently hot and previously naked.

When King asks about the settlement, it's the most provocative question he, given his limited ability as provocateur, can ask. But if Howard Stern asks about the settlement, he's actually asking about the settlement. When he wants to get inappropriate, we'll know.

III.

Focusing on the specific case of a man saying something "inappropriate" about the woman he's talking to (as opposed to a general comment, e.g. "I like hookers with a little mileage on 'em"):

If you accept that the kill switch changes the focus from content to character, then what she's doing isn't judging the words, she's judging you.   Some men don't understand this mechanism, and it is both the cause of the conflict and the explanation for why the kill switch succeeds: the woman has a brain and a life experience, and she has you figured out. She knows you, probably better in this single respect (sex) than you know yourself.

You don't really get that she has this ability-- any abilities; you assume she knows nothing about you other than what you tell her, you assume she is less intuitive than you, whether it be because you are older or perhaps "smarter." The exact opposite is true. Because you don't appreciate this, you think you are fooling her by masking your real interets with neutral phrasing. ("Oh, what kind of a bathing suit was it?")

The sum total problem you are having is this: you don't see her as a person, you see her as...

You think you are seeing her as a single, complete individual, but you are mistaking your undivided attention to her as perception of her.

Consider the extremely awesome scenario in which your female coworker gets breast implants. What is a not-inappropriate way to comment on it? Answer: there isn't any. You either can comment on it, or you can't. And you know who you are. And she does, too.

IV.

So what can you do if you're at the wrong end of an "inappropriate?"

(Part 2 soon)

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===== ====== ===== The Last Psychiatrist: Advertising's Hidden Second Message

the question isn't why he is shown wearing a man purse, the question is why it takes two people to buy auto insurance

There are others in the same format: clueless fool is missing on life because he's busy with his phone.

(Not sure I get it. Why would a Windows phone make me use my phone less? Oh, now I get it.)

II. Who can we laugh at now?

On the Ron & Fez radio show-- probably the best radio show on the air today, and if you bring up This American Life I swear to Christ I'm coming over to set your cats on fire. "This week on This American Life, some banal idiocy, set to jazz breaks"--kill me-- on last week's Ron & Fez show someone brought up the above father/son baseball tragicomedy as an example of how white men, especially fathers, have become the accepted brunt of popular humor.

You can take that back a few years to the popular sitcoms, doofus white guy married to some hottie six grades smarter than him, not particularly manly or strong or motivated, the message apparently being that what women want are men too apathetic to cheat.

So it's the same old three chords sung to different lyrics, hey, this song is so unique because I haven't been alive long enough to have heard the same thing 8
trillion other times, let me get a T-shirt as well. But there's another
song in the background and you have to turn up the bass to hear it.

III. So why are the white guys the easy target?

It's not arbitrary, "hey, we did the pollacks and the indians, who's next?" And no, neither is it the completely imaginary hope that the media is so politically correct/racially neuralgic that they wouldn't dare EVER to make fun of blacks. e.g. when the corporate dummy drops the phone in the urinal:

and then goes right back to using it, the corporate dummy has to be a white guy and the corporate black guy gets to roll his eyes at him.

"Really?"

(yeah, but the white guy fished his hog out one handed. ZING!)

And when this thigh-hi wearing succubus

tries to turn him on, his penis should have instantly become a Staff of Osmium and Aggravated Assault, but he just searches for Activia deals. Not-noticing-husband has to be cast as a late middle aged white guy.


coincidence

And when the son plays outside with his Dad and his Dad is more interested in ESPN than in playing with his son, such that the kid throws the ball at his Dad's head on purpose--

--and even gets away with it, that Dad will be white and that sport will be baseball. Or soccer:

"...so I can actually watch my son's game, and not be that guy."

If you agree with all that-- father, husband, provider, dummies all, because they're safe targets that can be shown to be dummies-- then I can tell you something: you're white and a dummy.

Yes: all of that is just rationalization. TV programming may care about political correctness but advertising does not, at all, unless it can move product. Advertisers will airbrush a hidden vagina into an Absolut ad just on the chance it gets you to rethink sobriety/marriage, so believe me they have no problem putting black men in black face if it gets you to buy another Happy Meal. Advertisers aren't pro-black, I'm not sure there even are any blacks in advertising and that part's not a joke, they're not civil rights advocates, they're snipers from Psy Ops.

can you detect the subliminal message?

Advertisers make white guys into dummies because (they hope) it helps sell their product; but they're only going to link their product to a message that already exists. Unfortunately, by piggybacking their product on that concept, they are making the consumer believe that the concept is already accepted common knowledge. Advertisers didn't choose to live like this but that's how the mutually reinforcing symbiosis works. Like I said, advertising isn't our window on society, it is society's window on individuals, and these white guy-as-dummy advertisements are telling you that the reason white guys are picked on is because we hate them, and we hate them because they have let us all down.

Whatever your racial preference, agree that the world to this point was owned and operated by Whitey & Sons, Inc, and boy oh boy, did Sons butcher it. From the "economic crisis" to "unnecessary wars" to widening income gaps, global warming to outstandingly bad television, the world/America was promised there'd peace, prosperity and tube cars in 2010 and now it's worse than it was under Carter. The military said they could protect us, Goldman Sachs said stocks would go up in the long run, Congress said they got this. Nope, nope, nopedy dope.

The heirs of the world's everything have dropped the ball and squandered their lead. I don't know when we'll ever have a black President again, but I can/could have/did tell/told/tell you that the one time in post-soviet history where it was a foregone conclusion was 2008. Even overt racists voted for him, how much worse could things get? It's the same reason why downward spiraling Catholicism got itself a German Pope; why poster child for Euro bankruptcy Iceland went with a gay prime minister in 2009-- its most popular PM ever. It's not progressivism, it's a hail mary longshot after 3.5 quarters of fumbles and incompletes.    None of these events are examples of history in the making, they're history repeating itself. All of this has happened before and it will happen again.

IV. That's not me.

But those men in the ads are just "regular guys," which tells you that the disappointment extends to anyone who had privilege and power: fathers, husbands, suits. It doesn't matter if you think you earned every dime or it was handed to you, what others-- including yourselves-- see is that those who have are doing a terrible job with the present and an even worse job with the future.

What kind of a husband doesn't see that his horned up wife is trying to connect with him? A self absorbed man. What kind of a Dad doesn't even notice he has a skull fracture? A self-absorbed man. So how do you expect them to find cheap renewable energy? That's what society is angry about.

Notice that these men aren't absent-- the guy got dressed in silk pajamas, the other guy is in a baseball uniform, "what else do you want from me?" -- but they're not engaged. I can cite a million examples of this: hovering around your kids every second of the day; the decade plus explosion of husbands in the kitchen (I'm doing something for the family but don't really have to interact); "man caves" (at least I'm home and not at some bar) and hyper involvement in kids' schooling but not their schoolwork. Fake news and fake sex over real news and real sex, bullying laws and bike helmets, and no kid outside alone, ever, too many texting drivers, serial killers and pedophiles (there but for the grace of God and unforgiving laws go I.)

Be careful, wildpeople, if you think you're not the hated white guys in these ads. It isn't about being white or being a guy, but about the class of people who have inherited the earth and then withdrawn from it, leaving it to entropy. Those people are the privileged middle aged-- the Dumbest Generation of Narcissists In The History Of The World, and society hates you. That's why, in other Windows Mobile ads, these women are portrayed positively, as using the phone to connect:

while these women are jerks because they're using the phone to disconnect:

Neither do hispanics get a free pass-- not if they've assimilated into the middle class, taken advantage of its malls, and then beat a hasty retreat:

Society is disgusted by all of you, even as you are disgusted by it. But look up at the ads, the ones who have to suffer for it are the next generation. The ones you suffocate with your physical presence. "We always eat dinner together as a family." Yeah, well, maybe you shouldn't.

the balance of power in the United States for the next 25 years

V. 99% of society's problems are insoluble; the other 1% is being deliberately ignored

The quick point is that your constant physical presence isn't doing anyone any good, and as for your kids it is slowly/rapidly melting their soul like Red Bull on gastric mucosa. But the larger point is that everyone around you feels your apathy, it senses that you are zombies going through life, you would much rather be elsewhere. Like on your phone.

If you would be honest with yourselves-- which you cannot be, this isn't an insult but a description of the pathology-- you would realize that you are blowing off your kid and your wife and your life not to rest or relax or take a minute to yourself but to withdraw from reality, because in reality you are only a fraction of what you thought you were supposed to be by now, time to buy another phone and hope it connects to the Matrix.   And you withdraw at home because the boss won't let you do it at work but at home the kid has no power to stop you. Neither does your wife, who anyway has to work. Why does she have to work? Oh yeah, you let her down.

That withdrawal from reality has not gone unnoticed-- not by your kids or your spouse or the voters or the networks, they know you like programming that lets You Decide, and the advertisers use that to sell a phone. (The vodka sells itself.)

Truth hurts, me hearties, or so the saying goes but in your case not so much, the only truth that matters is what you believe in and that won't ever hurt you. And you believe Bush and the liberals and divorced parents and gays and blacks and the Christian right and fossil fuels and Xbox are all to blame, meanwhile you yourselves create an ad where your kid hits you in the head with a baseball and you don't understand the message that the problem is you. It is always you. And unless you change that thing first, everything else will be futile. As the great Marshall McLuhan once said, "know thyself, mofos, know thy mother fucking self."

---

You may also like:

Advertising's Collateral Damage

---

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===== ====== ===== The Last Psychiatrist: The Coming Global Collapse, Sponsored By British Airways

if you can supply the prose I can supply the crystal ball

If you're even moderately interested in the financial news, you've probably seen this:

Wow. What makes it scarier is that this is in the Telegraph, which, in June 2008 reported:

I remember this story so well that when I needed today to find the link, I remembered the full title. Same newspaper, same author. I'm sure I'm not the only one who saw the similarity. And, of course, two months later the freefall started, and the S&P lost half its value.

II.

Maybe it's my... perspective... but when I saw the story, something else caught my eye:

The 2008 article had 293 comments. The average Telegraph story gets 20 comments.

My first, cynical thought was: they wouldn't make up a story to generate traffic and ad revenue (British Airways), just because they know it worked the last time, would they?

I mean, "global collapse" is in quotes, right? Soc Gen had to have said it, right?

III.

A look at the actual report shows something a little different: Soc Gen outlines 3 possibilities-- Bear, Central, and Bull scenarios, each detailed with unnecessarily complex graphics.

They don't think the "Worst Case Scenario," will happen, they are just describing it. Their actual belief is stabilization in 2009, and recovery in 2 or 3 years.

IV.

So why report it it this way? Why write a news story about something Soc Gen doesn't believe is going to happen? Before you answer, consider that they only wrote about the "worst case scenario," not the Central and Bull scenarios.

It's bad enough that the story is misleading, and that it provides no useful news. What makes it dangerous is that it is misleading precisely to draw readers; and by becoming popular it then causes things to happen.

Newspapers are not objective informational resources, they are blogs. The sooner you internalize that comparison, the sooner you will be free.

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http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: The Communists Say James Bond Is Anti-Communist
The hell you say.

Say the Russian communists:

The group appealed to [female lead] Kurylenko, who was born in the former USSR: "The Soviet Union educated you, cared for you and brought you up for free but no one suspected that you would commit this act of intellectual and moral betrayal... [the movie wanted] to show that a Ukrainian girl sleeps with an American. It's a part of information and psychological war."

Previously, they hated Indiana Jones And The Kingdom of the Crystal Skull, and specifically Cate Blanchett (though for the wrong reasons.) (Oddly, no complaint about Kurylenko with an American agent in Hitman.)

The attack is obviously anti-American propaganda.

The party's leader, Sergei Malinkovich, said: "Everyone knows that the CIA and MI6 finance James Bond films as a special operation of psychological warfare against us. This Ukrainian girl sleeps with Bond and that means that Ukraine is sleeping with the West." (emphasis mine.)

Standard stuff: Assertion fallacy, misleading qualifier "special," elevated importance by using "operation," personalizing it, etc. None of his points are accurate-- they're not supposed to be, they're supposed to create a sentiment. The move is to use a many words of different meanings as possible, thereby immunizing the other words, to that even if one is detected to be false, the reader can think, "well, that's just one small mistake."

They don't even get the movie right: Bond isn't American, Kurylenko's character "Camille Rivera Montes" isn't Russian but Bolivian (ok, half-Russian), she doesn't sleep with him...

But it's neither directed at Kurylenko nor even Bond viewers. It's directed at Russians, it's an appeal to return to the Communist Party. The West is against you, look how we fight for the honor of our people.

II.

Or maybe not.

This group isn't the actual communist party in Russia, it is a communist group in Russia. It's best described as a-- fan club. By my estimation, it has 44 members. You know why I think that? Because that's how many people visited their site today.

And over the past month...

This story hit Russia and the niche James Bond sites on Oct 27, and the American/British media November 1.

If your communist party can't get more than 14000 hits even with every news outlet on the planet carrying your story, it's time to try porn.

So perhaps this isn't propaganda for the communist ideology, but rather a press release for themselves, for their specific club. The press equivalent of trolling for website hits.

III.

But as it took me no effort at all to look up this fake group (started 2003) and their inaccurate postings, why didn't any other news media do this?

It makes sense that the studio people love this kind of publicity. If anything, this makes James Bond films look better, suddenly they have some indirect, but real, effect in winning the Cold War. And I won't even disagree with that sentence.

But why would the news media carry this? I'm assuming they don't think of themselves as tools of communism or of Hollywood, so why would they repeat, dozens of times, this story? Not just contentless, but misleadingly contentless. For example, you might conclude that communists are actually upset, or idiots. Or that this Bond movie is just like the others. Etc.

Don't make the mistake and think this is fluff, like the story about the Madonna divorce. That story is fluff, but fact. This is none of those things: it is musak, its purpose is to convey mood. You leave with no actual information, your own empty prejudices are reinforced (in any direction-- it's your choice how to interpret it) and you're left, again, thinking you know something when in fact you know less than nothing.

===== ====== ===== The Last Psychiatrist: The Conspiracy Theorist's Guide The Financial Crisis

Now, with boldface and exclamation marks! And only most of it is a joke!

Question: How do you create the impression of a classless society so the proletariat doesn't rise up and beat you with their ipads?

Answer: you make sure everyone can afford everyone's products.

So what becomes the marker of class, if not possessions?

Services. A nice car is less of a status symbol than having a housekeeper, or cook, gardener, vacations, plastic surgery, restaurants. Only a chump says, "I own a Lexus." A real player has lunch at Morton's. Or better, breakfast at the Watergate.

But aren't those prohibitively expensive for all but the super rich?

Not if we use illegal immigrants. Saved!

But...

The only reason you can afford to go to Morton's and brag about it is that at several points in the chain, from agriculture to dishwasher, cheap labor was used. Otherwise that steak you ate would cost nineteen thousand dollars. Yeah. Google it.

And if it was nineteen thousand dollars, Morton's would go out of business, laying off however many actual citizens still work there. See? Thank your "inept" border police for your steak and your job.

So it's all about labor costs? All of this? The boom, the bust, taxes, healthcare reform-- it's all about labor?

Four questions about the Civil War:

How many southern whites owned the 4 million slaves?
Why did poor southerners who did not own slaves still support slavery?
1857: a book, a state, a panic.
What did the railroad tycoons give the Confederates for Christmas in 1868?

So it's all about trains?

As throughout history, from slavery to outsourcing to the underground economy, it's all about cheap labor. And you know what? As long as you can afford your MacBook Pro, you're not going to do anything about it. Oh, you'll complain that Bush lied, for sure, but a ten hour battery means you've got plenty of porn time. Enjoy your right click button, be-atch!

But didn't Arizona just make illegal immigrants... illegal? What are they going to do for cheap labor?

Hmm.

"Some [Phoenix] farms use inmates for relief from labor shortages." Phew. Thought we were going to have to deport them.

Yeah, but what about non-manual labor jobs?

Like prison call centers? Or graphic design? Dell used to use prison labor, but stopped in 2003 because it found cheaper labor elsewhere...

How much to they pay?

Oh, like, 50 cents an hour. Prison labor has been on the rise since Carter, kicked into gear in the 1990s, and is due to for a rediscovery.

Extra extra credit: when and why did America achieve moral clarity and outlaw the use of cheap prison labor?

Irony or design? How is it that Americans have some of the worst high school scores in the world, but on the other hand see college as an entitlement?

"...and Columbus thought the earth was flat and Jamestown invented the massacre..."

Can you summarize all this in one short quip?

All of this has happened before and it will happen again.

II.

I DIDN'T LIKE THAT BOLDFACE GUY'S LINE OF QUESTIONING. EXPLAIN YOUR LIES.

A boom/bust cycle has been in place for millennia. That's right, well before the Bushes colonized Saudi Arabia. The modern incarnation has been supported by the Global Elites (Rockefellers, Trilateral Commission, The Bilderberg Group, RAND corporation, reverse vampires) behind the backs of sucker politicians, e.g. whatever Treasury Secretary happens to be in office.

BUT WOULDN'T FORMER TREASURY SECRETARIES COMPLAIN?

how can they speak if they have no breath?

Secretary of the Treasury/CEO of Alcoa/Chairman of the RAND Corporation Paul O'Neill, in 2001, wrote that there was a financial contagion coming, and as investors saw it spread among emerging markets, they would pull out their money, worsening the contagion. "Hey, hey, who asked you?" Fired 2003.

Replaced by John Snow, former CEO of CSX. As everyone/no one knows, right before he was appointed Sec. of the Treasury in 2003, he sold CSX to the Carlyle Group, the secret "private equity" cabal controlled by the Bush family. It also owns Dunkin Donuts!

In 2004, an "investigation" discovered he had "accidentally" bought $10M of Fannie Mae debt back in 2002; to "avoid" conflict of interest, he quickly unloaded that debt in 2004, and was cleared of ethics charges. What luck!

He left in 2006 in order to "die" of "cancer." He was replaced by the current Secretary, Hank "go fuck yourself" Paulson.

What about the other Secretaries?

Carter's Treasury Secretary G. William Miller, inventor of Stagflation and the Chrylser Bailout: dead 3/2006.
Clinton's Secretary Lloyd Bentsen: "Bentsen was awarded the Presidential Medal of Freedom, the nation's highest civilian honor, in 1999 by Clinton. "Under his leadership in 1993, when some of the rest of us had our doubts, we passed the economic plan that paved the way for what is now the longest peacetime expansion in our history." Nope! Dead 5/2006.
Donald Regan: "After Wall Street and government, I decided that there had to be more to life than the stock market, golf and drinking." The hell you say! Erased 2003.
Carter's first Secretary, Michael Blumenthal: fled to Berlin, supports Obama.

If you're counting: three dead in 2006, two fired/dead 2003, and one still at large.

WHAT ABOUT FORMER SECRETARY PAUL VOLKER? HE'S NOT DEAD, IS HE?

Oh, you mean founder of the Trilateral Commission, along with Alan Greenspan? And member of the Bilderberg Group along with Donald Rumsfeld and Paul Wolfowitz? No, he's fine. They're all fine!

BUT THE PICTURE BOX SAID IT WAS ALAN GREENSPAN'S FAULT FOR KEEPING RATES SO LOW FOR SO LONG.

Exactly. It was also Toll Brother's fault for making houses as impossible to resist as they were to afford. And Aeropostale for making great looking Ts that are just the right side of too small.

BUT...

You look a little pale. Here, have a bottle of water. It's by Coca-Cola!

BUT IF THEY PURPOSELY LET THE MARKET CRASH, THEY'RE SINKING 401(K)S-- THAT MEANS THEY WILL INEVITABLY HAVE TO INCREASE SOCIAL SECURITY. ISN'T THAT THE OPPOSITE OF WHAT THEY WANT?

That's the scam, yo.   Like the drug dealer on the first encounter, once you're hooked, once you're reliant on the government for healthcare, and social security, and everything, you'll never dare revolt. They own you forever. Sure, you'll post idiotic rants on blogs, but do you think they care about that?

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===== ====== ===== The Last Psychiatrist: The Copenhagen Interpretation of Lost

If you follow Lost, you know that there are two parallel universes, one in which Jack et al are on the Island conflicting with Locke/Black Smoke Monster; where Charlie drowned and Faraday is a physicist who is killed by his future mom; and the other universe in which Jack is a practicing doctor, Desmond a rich playboy, Charlie's alive, and Faraday wants to be a musician. &c.

All are free to speculate about what it means.    But it's valuable for other reasons to offer two understandings of the concept of parallel universes.

In the popular understanding of parallel universes, every decision or possibility splits the universe into simultaneously existing, equally "real" and autonomous universes, e.g the cat is alive in one universe, and dead in another:

So when you choose A over B, your universe proceeds accordingly, but another is split off next to it.

But you see that the possible universes trail behind you. You make a choice, there's a split, and you leave exhaust and a universe behind. What's particularly interesting about this idea is that while it purports to be a solution to the difficulties of quantum mechanics, it actually doesn't require quantum mechanics at all. It's a purely semiotic interpretation: the universe splits. No math, no confusion. You can't communicate with that universe in any way, so is it "real?"

The Copenhagen Interpretation has it the other way. In this case, all possibilities exist before you (to varying probabilities), but once a selection has been made, all other choices are obliterated. Reality becomes a series of successive obliterations of potential realities. Just like middle age!

It's immediately arguable that since these are all statistical functions, they do not necessarily apply to an individual case (i.e. to your choice of A or B) but instead describe the system of such events. In the same way, an equation might describe how oxygen molecules (O2) are dispersed in a room, but it doesn't predict in reality where each molecule is.

The point, for Lost, is that by having Desmond, Charlie, Jack, et al become aware of this other universe (e.g. Desmond's flash of Charlie drowning in the car) they are not jumping to the other universe, but in fact obliterating the one they are in, in favor of the other (Copenhagen interpretation.) This makes Locke/Smoke Monster's desire to leave the island, and the feared consequences ("everything will cease to be") more accurate. Locke isn't just changing universes, he is causing that one to obliterate.

===== ====== ===== The Last Psychiatrist: "The Copycat Effect:" Does Reporting Violence Lead To Violence?

A reader asked me to read his book before saying that copycat suicides is not a real phenomenon.
To be fair, his book is really good. It is worth the price even as a reference guide/catalog of suicides and homicides that share similar characteristics, which are striking. While the majority of the information is a google search away, the fact is that he actually did the searches.   It's also a good read-- it neither bores you nor crams the conclusions into your head.
But, I respectfully disagree. I think.
The main disagreement I have with the book is that he conflates two phenomena. His stated thesis of the book is that media reporting of violence and suicides begats copycats. However, in support of this premise, he uses examples of the media itself (e.g. movies) causing copycats.
A perfect example of this is the Werther Effect, so named for the Sorrows of Young Werther, the 1774 comic book by Goethe in which the protagonist kills himself because he can't get the girl.    Subsequently, there were numerous copycat suicides-- staging it (same clothes, same desk) as Werther in the novel. Ok, I get it-- that's a copycat. But that's not an example of media reporting causing copycats.
In contrast, here's an example of a reporting-induced copycat: Coleman relates the Bergenfield Four. For a few months, there were rumors that a bunch of kids who called themselves "The Burnouts" had made a suicide pact. In September of 1986 their leader killed himself; in March of 1987 four others carbon monoxided themselves in a parking garage, leaving a note that clearly linked the deaths. One week after that, a cop found two other kids trying to do the same thing in the same garage. The day after the original four suicides, but in Illinois, two other teens suicided the same way (in a garage, in fact.) Coleman writes that by checking newspapers, he counted 22 teen carbon monoxide suicides in two weeks-- 47 in a month.
But then there's the case of Barry Loukaitis, who in 1996 shot two kids and a math teach, and said he got the idea from Stephen King's Rage, Pearl Jam's Jeremy, Natural Born Killers and The Basketball Diaries. Coleman writes that "the media attention...triggered a series of similar events." So, in these copycats, was it Basketball Diaries or the evening news? It's hard for me to see how the news can be more influential to a suicidal kid than the movie itself-- do kids even watch the news?
In fairness, he does cite numerous examples of media reporting induced copycats (check out the chapter "Planes Into Buildings" for a wild ride) but overall the argument is weakened by using both together. I left the book reasonably convinced that media can inspire copycat violence, but not that they inspire violence itself. In other words, I think those Werther scholars were going to kill themselves somehow, but they decided to shoot themselves (as oppposed to self-immolation) because of the book.
The distinction-- media or media reporting-- is important because the solutions are different. Here's an example: the book opens with the story about how one month after Marilyn Monroe's suicide, 197 (mostly blonde women) "appear to have used the model," to suicide-- an increase in the suicide rate of 12%. Furthermore, the suicide rate never went down after that. "This is the copycat effect working with a vengeance." Maybe. Or maybe the graphic description of the suicide wasn't to blame, but rather that a huge icon had done it at all. Are they copying her, or is society ripe for self-destruction? Either way, should we not report that Monroe killed herself at all? How much do you control information to protect the people? If the government is doing the controlling, then I can't imagine the answer should be anything other than "not at all, get the hell out of my face."
I've always said that the "mainstream media" is neither liberal nor conservative-- they are sensationalist. Of course I think they overreport, and overdramatize unusual violence. But I see that as more of a symptom of our culture than the cause of anything. You could close down all news portals, it won't change the amount of violence. Sure, maybe you wouldn't have thought of playing Russian Roulette. But you were going to come up with something.
Coleman wrote a thorough book, using the type of diligent research the CIA is supposed to be good at: compiling open source information and forming links. I only partly disagree with his conclusion, and I am still open to further arguments. But I am against the solution.
It's worth remembering that, in response to the copycat suicides, Sorrows of Young Werther was banned in Germany. I know I am one of only 8 people who has actually read it, but do we really want it banned?    Maybe "dangerous" books need to be delayed by a generation to be published? And you see my problem.
Absent direct power or wealth, the only thing that keeps us free is information. I believe it is worth the risk of copycat suicides, especially since influencing the choice of the method of suicide isn't the same as influencing the choice of commiting suicide.

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===== ====== ===== The Last Psychiatrist: The C Team

back in the day

Monday was the 8-11 girls' soccer ("you know, it's really called football") tryouts for the A and B teams.

Her father had watched the practices. She was good, but was she A team good? It depended on the day. Precise and aggressive one day, distracted and chatty the next day. Some days she owned the ball. Other days she had to pee. And she was picking her fingers a lot.

He had given her some helpful advice: dribble up the right sideline because those right footed girls will have a harder time getting the ball away from you. Also when you kick on goal kick knee height, force the goalie to have to bend down.

He also told her that Hannah Montana ("Dad, that's not her name") was the evidently the dominant player on the other team, and when it looked like Hannah was going to go after the ball her teammates would hang back and out of her way, but that meant the ball was unguarded.   That was a good time to go after it.

It was the kind of advice he wished someone had given him back when it was his turn.

II.

Ok. There were four obvious A teamers, leaving seven spots. Call it 6. If Jane and Sue made A team, she'd definitely make it. Kathy and Claire were older and if they got picked because of seniority then there'd be only two or three open spots left. Tight.

The Dad said this: whatever team you make, you have to earn it everyday. You make A but don't keep up, they'll send you down to B. Make B but work hard, and they'll move you to A. (That's life, he thought. That's what this is all about anyway.)

Besides, they're not going to let someone too good be on B for very long because they'd dominate the game. The coaches want everyone to get a chance to play. (Sophistry in the service of the ego. That's life, too, but it's not a lesson he wanted her to have to learn.)

III.

Tuesday: no call. But Kathy heard: A team. Wednesday came: no call. Claire got A team. Wednesday night: Hannah Montana found out she was B. That made no sense.    Other mothers checked in, they heard A team was filled. "I guess she made B," they apologized in advance.

Then there was the news: there were too many girls. Or plenty of girls. So the coaches created a C team. Uh oh.

Thursday came.

Then Friday.

Then Saturday.

Then Sunday.

Then Monday.

She went into school: everyone else had heard. "What'd you get?" Claire asked.

"I don't know."

"Oh. My. God. That means you got C team!"

She picked her fingers a lot that day. If she made at least B, she promised herself she wouldn't buy a soft pretzel with the milk money and wouldn't throw out more than five of her grape unless... unless she finished all her carrots. And she would stop trying to control everything.

When she got home her Dad was already coping with the news. "I'm so sorry. They said you made the C team."

She started not to cry. "That's okay," she said. It wasn't.

IV.

This is another one of those times you make it as a parent or you move out because your presence is a biotoxin to everyone in the family. So: as terrible as it was, he could use it to make her into a better person. First the obvious lesson: failure happens, nothing is guaranteed. Life is competition. Parents and the government can't bail you out of everything.

Ok-- facing her classmates and having to tell them that she was C while still maintaining her dignity-- without hiding behind "we're all special in our own way"--- there was value in that. "What should I tell everybody at school?" she asked. "(Can I lie?)" No. "Just tell them: 'I made C team. I don't know how it happened, I feel pretty awful about it, but I'm going to make the most of it.' Whenever you talk, be straight."

And of course she could get better. Let's face it, she hadn't worked that hard. It's not like she drilled every day in her yard. Getting on A with only Saturday practice could easily make you think you're better than you are, more deserving than you are, and when the inevitable failure comes from boys or grades or lotteries it crushes you right through your paper foundation. Next thing you know you're 15 and one of your friends has an older brother who knows where to get some pot and how to have sex without getting pregnant.

Starting from C and and getting to A is the biggest accomplishment, it's what makes you a man. Or woman in a man's world.

V.

"You have lots of potential. Nothing is set in stone. You're still young. Practice, practice, practice. You can be anything you want." He had plenty of advice, quite practical. Keep it coming. In this way he might avoid the thought: this is another thing at which she will not be exceptional. The thought came anyway.

He had never wanted to be a soccer star, he hadn't even played very much, but at 50 it was inevitable that he would never become a soccer star. Now his daughter wasn't going to be a soccer star either which meant that he had failed at soccer twice. Another closed door just got boarded up.

One by one his daughter failed or lost interest in the things he had never done. There was no time left for him to be exceptional at anything though his daughter represented a wide open future with millions of open doors. But she spent the first years of her life closing them. "How would vous like to go to un Francais immersion camp?" he had once asked. "French?" she had replied, reaching for a door, "I don't know..." Slam.

The only thing left for him was to become father of. "My daughter is a soccer star, " he wouldn't have to say, everyone would just know it about them. And he'd sit at the practices and give her advice and then afterwards a quick snack and off to violin, because she had the potential to get to Julliard if she practiced, and, crazy passing daydream, one day People would do a story about him.

But it wasn't going like he had imagined it would. Somewhere in his brain he had thought that maybe his daughter's success would keep him from getting old. He had never been able to get off C Team, and the last thing left that he might be excel at, fatherhood, he was proving to be as mediocre as in everything else.

When you are a narcissist, children, even the good ones, are a narcissistic injury. That story almost never has a happy ending, but it does end.

VI.

There is no redemption for him because the point isn't his redemption, it's hers, and you either get that or you don't. Most people don't, which is why there's a C team at all.

When she said, "that's okay," of course it wasn't, and something in his brain shorted and he was able to resist all of his best impulses and instead just hugged her and said, "there's not much I can say to make this better, but I love you all the time, all the time. So there's this." And he opened a bag and pulled out the next Harry Potter movie which she had been begging for every day, ("please please PLEASE!") but at those times he had pretended to be the Dad that People would one day profile, "you have to finish the book first because I want you to learn that the books are always better." Shut it, old man.

Sometimes when a little girl is sad you just... fix it. And this time it made her smile so much and for so many reasons and after dinner they sat down together and watched it. That was all. It was about a boy who didn't have a mom or a dad, and he had to make it all by himself, and he did.

Soccer wasn't going anywhere. But she was.

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===== ====== ===== The Last Psychiatrist: The Dead Sea Effect In Academia
And I am ashamed.

Bruce Webster writes about information technology, and describes what he calls the Dead Sea Effect. (The post is well worth reading.) The Dead Sea is land locked; water comes in by the Jordan River, but no water leaves except by evaporation. In IT, new hires come in, but who leaves?

...what happens is that the more talented and effective IT engineers are the ones most likely to leave -- to evaporate, if you will. They are the ones least likely to put up with the frequent stupidities and workplace problems that plague large organizations; they are also the ones most likely to have other opportunities that they can readily move to.

What tends to remain behind is the 'residue' -- the least talented and effective IT engineers. They tend to be grateful they have a job... They tend to entrench themselves, becoming maintenance experts on critical systems...
Sadly, this is even more true about academia. "Grateful to have a job" is translated to valuing the university appointment even more than money. You can't really tell someone at a party you make $50k more than other people in your field, but you can tell them you work at Yale. And here's the thing: the fact that you work at a university is actually trivial. It actually has no value at all except to you, as a means of reinforcing (or creating) identity. Your family would actually be better off with the extra $50k

"...entrench themsleves, becoming maintenance experts..." is translated to a focus not on output, but on process. The death of a university can be reasonably measured by the increasing ratio of assistant and associate professors on committees to number of post docs. I wonder if you can't remove the denominator and still have a reliable gauge.

But the more important result is that academia produces mediocrity. I know people will disagree, but they're wrong. Mediocrity in education is a given; teaching assistants teaching classes; multiple choice exams; grades in general-- they're not there to promote excellence.

And what are those too-busy-to-teach professors doing? Mediocre research. I've said enough about the pointlessness of yet another clinical trial. But even basic science research suffers. It's not that the ideas or goals are mediocre-- it's the approach. Plodding, unfocused-- the mind is on the grant, not the result. "What experiments will the reviewers want me to perform?" The contest between those in academia and those who leave would have well been settled by Celera vs. Human Genome Project, had not President Clinton changed the game.

Henry Kissinger said: university politics is vicious precisely because the stakes are so small. Actually, a number of people said it. Because it's true.

Academia is a trap. It pays you with secure insecurity. You settle in and think, I am never going to leave this. It confuses you, it changes reality. I make only 20% of my income from my university job, yet whenever anyone asks me what I do for a living, I tell them I work at university. Worse-- I actually believe it, it's part of my identity, even though it is factually incorrect. Your focus is not on why you are there, but on how to stay there, or even to advance, in that irrelevant hierarchy.

Academia is like being in an abusive marriage. You know you should go, you get nothing from being there except misery and pain, but leaving is nearly impossible, so much has to go into the decision to leave, so you stay, try to make it work. Maybe it'll get better, it's really not any different anywhere else, maybe it's not him, it's you, if you lost twenty pounds or got a second grant maybe then they'd like you...

Jesus, I'm in an abusive relationship with my job.

I think it may be time for me to go.

Academics are not bad people, obviously, and they have their role in the Matrix. But the real talent, the ones who produce, they all graduated and left-- or never graduated at all.

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===== ====== ===== The Last Psychiatrist: The Decline Effect Is Stupid

we were surprised to find the data fit well within the two axes. Further research is needed

Is there something wrong with the scientific method? asks Jonah Lehrer in The New Yorker.

The premise of the article is a well known phenomenon called the Decline Effect. As described in the story, that's when exciting new results, initially robust, seem not to pan out over time. Today a series of studies shows X, next year studies shows less than X, and in ten years it's no better than nothing.

To be clear, this is what the Decline Effect is not: the finding of better data that shows your initial findings were wrong. The initial findings are right-- they happened-- but they happen less and less each time you repeat the experiments. The Decline Effect is a problem with replication.

An example is ESP: the article describes a study in which a guy showed remarkable ability to "guess which card I'm holding." He was right 50% of the time.   That happened. But in subsequent experiments, he could do it less. And less. And then, not at all.

Many critics of Lehrer's article read this and say, a ha! the real explanation is regression to the mean. Flip a coin and get heads nine times in a row: it could happen, but if we flip that coin enough times we will see that it is ultimately 50/50.

But that explanation is incorrect, the article explicitly states that the Decline Effect is not regression to the mean.

The most likely explanation for the decline is an obvious one: regression to the mean. As the experiment is repeated, that is, an early statistical fluke gets canceled out... And yet Schooler has noticed that many of the data sets that end up declining seem statistically solid--that is, they contain enough data that any regression to the mean shouldn't be dramatic. "These are the results that pass all the tests," he says. "The odds of them being random are typically quite remote, like one in a million. This means that the decline effect should almost never happen. But it happens all the time!..."

And this is why Schooler believes that the decline effect deserves more attention: its ubiquity seems to violate the laws of statistics.

Lehrer believes that the Decline Effect is an inexplicable byproduct of the scientific method itself.

So? What gives?

By now, many scientists have weighed in on this article, offering the usual list of explanations-- publication bias, selection bias, regression to the mean. But while these are real problems in the pursuit of science, the real explanation of the Decline Effect goes unmentioned.

A hint of "what gives" is contained in the rest of Schooler's quote, above:

...This means that the decline effect should almost never happen. But it happens all the time! Hell, it's happened to me multiple times."

The true explanation for the Decline Effect is one no one cites because the place you would cite it is the cause itself. I am not exaggerating when I say that the cause of the Decline Effect is The New Yorker.

II.

The Decline Effect is a phenomenon not of the scientific method but of statistics, so right there you know we are out of the realm of logic and into the realm of "well, this sort of looks like a plausible graph, what should we do with it?"   Here's the article's money quote:

But now all sorts of well-established, multiply confirmed findings have started to look increasingly uncertain. It's as if our facts were losing their truth: claims that have been enshrined in textbooks are suddenly unprovable. This phenomenon doesn't yet have an official name, but it's occurring across a wide range of fields, from psychology to ecology.

A wide range of fields from the almost entirely made-up to the slightly less made-up are losing their "truth?" This phenomenon isn't occurring in physics. You could (and people did) build a Saturn V launch platform on the unscarred edifice of Maxwell's equations, and then 40 years later build an iPhone on top of that same edifice. It's amazing what you can do with the black magic of electromagnetic theory.

Psychology, e.g., is different, because it attempts to model the particular minds of some humans at this particular time in this particular culture, and those models may apply 3 or 3000 years from now, or they might not. Ecology attempts to form a static model of the dynamic relationship of constantly evolving organisms to each other and their environment which we are wrenching to and fro in real-time. But there is no static "reality" in these fields to observe. In these soft sciences, the observation of reality doesn't just change the results, sometimes the observation actually changes the reality almost completely.

In these regression sciences, we throw a ton of data into Visicalc and see what curves we can fit to them. And then, with a wink and a nod, we issue extremely broad press releases and don't correct the journalists or students when they confuse correlation with causation. We save that piercing insight for the cushy expert witness gigs.

The problem isn't that the Decline Effect happens in science; the problem is that we think psychology and ecology and economics are sciences. They can be approached scientifically, but their conclusions can not be considered valid outside of their immediate context. The truth, to the extent there is any, is that these fields of study are models, and every model has its error value, it's epsilon that we arbitrarily set to be the difference between the model and observed reality. Quantitative monetary theory predicts that given this money supply and this interest rate, inflation should be 2%, but inflation is actually 0.4%. Then let's just set epsilon to -1.6% and presto!   Economics is a Science.

III.

To make its point about the Decline Effect-- and unintentionally making mine about science-- the article predictably focuses on the psych drugs that we hate to love to take, that keep the McMansions heated and the au pairs blondily Russian. "They were found, scientifically, to be great, and now we know, scientifically, that they're not!" Medicine is not a science, and despite the white coats and antisocial demeanor doctors are not scientists.   Docs and patients both need to get that into their heads and plan accordingly.   That why we say doctors practice medicine. If medicine was a hard science, doctors would not have been surprised and puzzled by the effects of some of these drugs. You can show me Powerpoint slides of depression rating scales for as long as the waitress keeps refilling my drink, but none of that "science" explains why imipramine doubles the mania rate, Depakote does nothing to it, and Zoloft lowers it, with apparent disregard for their scientific classifications.

The problem isn't the Decline Effect, the problem is you believed the data had the force of F=ma. No one should be surprised when medical "truths" turn out to be wrong-- they were never true to begin with. And if you made sweeping policy proclamations based on them, well, you got what you paid for.

IV.

But for all this imprecision, the criticism-- by folks like Jonah Lehrer-- directed at the "social" sciences is even worse. Eggheads are collecting data in routine and predictable ways. They are at least consistently using statistical analysis to analyze that data. It isn't art history by postdocs with warez Photoshop.

So when I read this, I have to manually push in my temporal artery:

Many researchers began to argue that the expensive pharmaceuticals weren't any better than first-generation antipsychotics, which have been in use since the fifties. "In fact, sometimes they now look even worse," John Davis, a professor of psychiatry at the University of Illinois at Chicago, told me.
Shiver me timbers. Okay, Professor Davis, now that your conclusion about the inferiority of the expensive drugs has been read by an audience twenty-five times larger than that of any study you've ever read, let alone written, can you please show us that data that supports your conclusion that atypicals are less efficacious? Oh, that's not what you meant.   I'm confused, what do you mean by "worse?" Wait, were you talking about depression or schizophrenia? OCD? I'm lost, let's back up. And while you're at it, please define for us/Jonah Lehrer the other technical terms: "sometimes," "they," "now," "look," and "even," because I have no idea what they hell they mean in this context, and, big money down, you don't either.

This is where the "scientific method" is breaking down. Not in the lab or at the clinical trial. It's breaking down in the sloppiness of the critics. If any researchers want to argue about the efficacy of new drugs over the old ones, there are ways and places to do that. The New Yorker is not among them, because it lets scienticians get away with sloppy soundbites, and leaves anywhere from nine to 3M layman readers with the impression that scientists "know" "the newer meds" are "worse."

And the moment you talk to The New Yorker, your misinterpreted statistical association becomes truth. Certainly for the layman's mind, but also in the mind of the Professor. I'm going to bring up Depakote again until I get a public apology-- do you know how many times a day I have to correct psychiatrists that Depakote does not have "a lot of studies" supporting its efficacy in maintenance bipolar-- let alone an actual indication?

Left alone in his office and a stack of contradictory papers, he probably wouldn't be so flippant about it all. It's slow, excruciating, unexciting work that is the pursuit of science.

But that won't get you any grant money, let alone quoted in The New Yorker.

V.

An example:

What Møller discovered is that female barn swallows were far more likely to mate with male birds that had long, symmetrical feathers. This suggested that the picky females were using symmetry as a proxy for the quality of male genes. Møller's paper, which was published in Nature, set off a frenzy of research. Here was an easily measured, widely applicable indicator of genetic quality, and females could be shown to gravitate toward it. Aesthetics was really about genetics....In the three years following, there were ten independent tests of the role of fluctuating asymmetry in sexual selection, and nine of them found a relationship between symmetry and male reproductive success. It didn't matter if scientists were looking at the hairs on fruit flies or replicating the swallow studies--females seemed to prefer males with mirrored halves.

That's what Lehrer wrote. I know you didn't read it all. Here's what you read:

"Females seem to prefer symmetric males."

The actual study suggested nothing about what the picky females were doing. Lehrer inferred it. By the time we get to the end of the paragraph all the reader remembers is that women prefer to have sex with symmetric guys, which is simply, undeniably, not true. But none of the studies in that paragraph every concluded that. They each made specific conclusions about the specific creature they were studying. And if you think I'm splitting hairs, then you are the reason for the "Decline Effect."

Scientifically detected associations, in specific situations and contexts, are then generalized by the popular press-- or at least by the profession's internal pop culture-- and those generalizations are used as working knowledge. Those generalizations, which were never true, are the starting point for the future decline in effect that Lehrer is worried about.

When the article then goes on to describe the breakdown of this sweeping generalization in studies after 1994 (on other species), it attributes that to the Decline Effect. It's not. When you look at the studies together, what you should have inferred is "symmetry is an associated factor in mate selection by females in only some species and not others and more research is need to explain why." Instead, the article attributes its inability to summarize the variety and complexity of nature in a 140 character Twitter message to an underlying failure in the 500-year-old guiding principle of science.

Worse, as the article points out, sometimes journals want to publish only confirmatory findings, which set the stage for the discovery of a Decline Effect later on. But the article doesn't go far enough: they're not looking for confirmation of a previous study, they are looking for confirmation of a sweeping generalization. Not: "Zyprexa is more efficacious on the PANSS than Haldol for schizophrenia," but "Don't we already know atypicals are better than typicals?" And then those same journals, in the future, will only want negative data because their new sweeping generalization will be popular at Harvard via a grant from NIMH, all the Pharma guys moved on to Ohio. That's not the Decline Effect: it's a pendulum swinging wildly from one extreme to the other, over a pit, in which is tied a guy. You're the guy.

V.

Here's an example of how sloppy science becomes enshrined as "truth" by popular press outlets like The New Yorker.

In 2001, Michael Jennions, a biologist at the Australian National University, set out to analyze "temporal trends" across a wide range of subjects in ecology and evolutionary biology. He looked at hundreds of papers and forty-four meta-analyses (that is, statistical syntheses of related studies), and discovered a consistent decline effect over time, as many of the theories seemed to fade into irrelevance.

===== ====== ===== The Last Psychiatrist: The Diagnosis of Borderline Personality Disorder: What Does It Really Mean?

A diagnosis of borderline personality disorder could, theoretically, mean that the psychiatrist made a serious attempt at evaluating defense mechanisms and ego integrity; or at least a matching of symptoms to DSM criteria. It's theoretically possible, yes. Other things that are theoretically possible include alien abduction, peace in our time, dual eigenstates, user friendly Movable Type upgrades, political discussions that don't rely on information from John Stewart, Daleks, recession with low unemployment, Independents, Madonna/whores, a benignly rising Russia.

Let's assume there's a difference between a diagnosis and a heuristic.
A diagnosis is based on pathology, or at least on a set of predetermined criteria. I diagnosis must be both reliable-- multiple doctors would find the same diagnosis when given the same information, and valid-- the diagnosis actually is the thing you say it is.
Many psychiatrists devalue diagnoses into heuristics, that is, they have intuitive "rules of thumb" that are extensions of their own cognitive biases. This isn't automatically good or bad; the heuristic is only as helpful as the bias. For example, if the last ten people who you saw that smoked crack also had syphilis, on the 11th you might apply the heuristic, "where there's crack, so there be syphilis, better get a blood test." Unfortunately, it could be applied the other way: the 11th patient with syphilis you see gets prejudged as a crack addict.
The diagnosis of a personality disorder is supposed to be valid, it's supposed to mean something. However, in general they are diagnosed very unrigorously, if such a thing can be imagined of psychiatrists. They carry nearly none of the implications of causality (except, once in a while, sexual abuse), nor do they reflect a distinctive understanding of a person's personality (e.g. borderline as distinct from narcissism.)
A good example is borderline. If a psychiatrist calls it borderline, it may or may not be, actually, borderline personality, a la Kernberg.   So if a patient happens to know she was diagnosed with borderline (which she rarely will-- it's kept secret or encoded as "bipolar") it doesn't mean she can look it up on the internet for more information, because that's not what the psychiatrist meant by the diagnosis. "Articulate" has a certain meaning, look in the dictionary; it is fairly consistent throughout all settings except one: when it is used by a white guy to describe a black guy. In that case, the word suddenly means something completely different than it ordinarily does: it means "not hung up about race." Here's the point: the black guy may actually be articulate, or not be articulate-- who knows? But white people know exactly what it means in that context. Similarly borderline: you may, indeed, have a borderline personality, or may not; but the diagnosis to the psychiatrist means something else. n other words, it's not at all a diagnosis, it's a heuristic.(1)
Devoid as these personality disorder heuristics are of their originally intended meanings, they do, however, reliably imply the same things to other psychiatrists. Those "things" however, are uncoupled from the "official" diagnosis. The heuristic may have a lot, or absolutely no, relationship to the diagnosis. In other words, the term "borderline" is immensely reliable among psychiatrists, but not at all between psychiatrists and non-psychiatrists, who think it means something else. What psychiatrists should have done is invented their own special word for the heuristic of "borderline." But they're lazy.
So, as a public service, I'll tell you what psychiatrists mean when they say borderline. Once again, I'm saying that this is how the diagnosis is used by many psychiatrists. If you email me and say that I'm a jerk for not understanding the term, then you need to go buy yourself a helmet.

First, borderline is a heuristic of countertransference: if the psychiatrist feels frustrated, or exasperated, then the patient is borderline.
Second, borderline is meant as a synonym for any of the following: needy, argumentative, touchy/hypersensitive.
Third, it is generally reserved for the following four types:

Very attractive female, who comes for problems the psychiatrist considers ordinary: men, work/school, problems with parents, etc. It is diagnosed here most often by female psychiatrists, and carries the connotation: "Grow up."
Overweight, typically white, female, who needs/wants benzos, especially Klonopin. The implications are lack of self-control, and reliance on external supports.
Thin female with a lot of anger. By example, the woman who comes for treatment of "depression" but describes most life events in terms of attacks, sleights, harm, etc-- i.e. power differentials.
Gay man.
If you are a patient, my point in telling you this iss not "why did they diagnose me with borderline?" but rather, "oh my God, are you telling me he thinks I'm borderline just because I told him if I don't get my twice a day klonopins, I'll freak out?"

Again, these aren't even accurate descriptions of the formal diagnosis borderline; number 3, for example, is better described as narcissism, especially when anorexia (restricting type) is involved. But her anger makes the psychiatrist uncomfortable, so it gets labeled as borderline.(2)   I hope you see two obvious problems: first, the term is used pejoratively; but, more importantly, giving something a label alters the environment, in this case in the wrong way. The above #3 female doesn't need limit setting, she needs mirroring transference, etc. (And don't forget about the narcissistic injury.)

But again, even though the term is used improperly and probably leads to worse treatment for the patient, it does mean the same wrong thing to most psychiatrists. So when I'm being referred a "30 year old borderline," I know almost exactly what I'm getting, even though it has nothing to do with borderline. Frustrating? You betcha.

But the sleight of hand is that it sounds like personality disorders are crappy and unreliable diagnoses and have little in common with their original meaning. In fact, most psychiatric diagnosis are equally crappy and unreliable. When you read articles saying "borderline is a pejorative term, and these patients are often really bipolar" what you need to understand is that "bipolar" is not a more valid or reliable diagnosis, it's simply another heuristic. It isn't less pejorative, it isn't more "real." It carries a different set of implications, but it isn't a more rigorous, more "biological" classification. It's not like saying, "it's not a unicorn, it's a rhinoceros." It is like saying, "it's not a unicorn, it's a pegasus."

This, by the way, is the reason why so many defenders of psychiatric diagnoses can't accept that "borderline" and "bipolar" are equally subjective terms. They say, "the diagnosis of borderline has very poor inter-rater reliability; bipolar has high inter-rater reliability." But reliability is not the same as validity. If you take twenty thousand members of the KKK, and ask them to "diagnose" the problem of contemporary society, their answer will be the same, i.e. reliable. But it's wrong, obviously. The diagnosis of bipolar is reliable, but in the same way as the KKK's diagnosis of society's ills was reliable. It may be completely wrong, it may be completely right, it may be partly right, partly wrong, in some cases but not others, etc.

If you want to know why I've used racial analogies throughout this post, it's because these are all, in essence, prejudices. "It's bipolar." "It's borderline." "It's poverty." "It's bad parenting." "It's..." Well? It's not really any of those after all, is it?

------

1. Referencing a joke from Fear of a Black Hat: "what's the difference between a slut and a ho? A slut sleeps with everyone. A ho sleeps with everyone but you." So here, the term "ho" actually has nothing to do with how many people she has slept with, under what conditions, money, etc-- in other words, it isn't the definition in the Oxford English Dictionary-- the single implication is that she didn't sleep with you, a fact which is actually not in the official definition. So she may, indeed, be a "ho" under the Oxford English Dictionary definition, or may not be. But when the word is used in conversation, everyone "knows" you didn't have sex with her.

2. Narcissism as a heuristic is reserved for either successful, or threatening, men; the countertransference is defensive condescension, as in, "go ahead and rant; you think just because you're a millionaire lawyer, you're going to intimidate me?"

3. (Wait, there was no 3?-- Here's a day to day description of what borderline is supposed to be.)

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===== ====== ===== The Last Psychiatrist: The Difference Between An Amateur, A Scientist, And A Genius

Around 1800, Herschel wanted to look at the Sun with his telescope, so to keep from going completely blind used different color filters to darken the image enough to be able to look at it.

What appeared remarkable was that when I used some of [the color filters], I felt a sensation of heat, though I had but little light; while others gave me much light, with scarce any sensation of heat.

Almost anyone could have made this observation. The point is what do you do next.

An amateur might think about this for a while, might even come up with a hypothesis involving an inverse relationship between "brightness" or "color" and "heat."

An amateur, if he is sufficiently motivated, might even be tempted to investigate this, which is what Herschel did.

Herschel refracted light through a glass prism.

And measured, with a thermometer, the temperature of each color.

Conducting the experiment this way would be sufficient for an amateur; he might even be pleased with himself for taking it this far. But Herschel wasn't an amateur, he was a scientist. If you're going to do it, do it right: he knew he needed a control. An amateur is satisfied with relative comparisons, "active comparators", "this color hotter is than this one." But Herschel wasn't going to fall for those shortcuts to hell. He placed another thermometer, outside of the spectrum, as a formal control. Actually, that's my mistake: he put two thermometers outside of the spectrum, as controls.

He found that each color had a different temperature, the red being the hottest, violet the coolest.

Take a moment and consider to what extent you knew (or did not know) this, today, with these principles firmly established in our everyday life. Think about what this finding would mean to Herschel. What kind of questions would he ask next?

Because Herschel wasn't an ordinary scientist. He was able to ask questions others would not think to ask. He looked at those colors, the ones that he had measured, and he asked, what is the temperature of the region after the colors?

He wasn't satisfied with what would have been an otherwise worthwhile experiment, nor was he constrained by what he could see and observe.

So? What do you think was the temperature of this region?

He found it to be even hotter than the red.

It's 2009, so you can guess that what he discovered was the infrared region. But you're putting that together already knowing about infrared light. He had to come up with a whole new explanation for why something that wasn't there was hotter than everything else.

An amateur is full of wonder and speculation, tinkering towards the truth but suffering from a lack of knowledge and idleness; he's not even sure if someone else has already made these discoveries. "Is this a worthwhile pursuit?"

A scientist performs experiments to confirm or disprove a hypothesis, and in that way he grinds out the truth.

A genius has three abilities, which are actually the union of amateur and scientist: 1. to know the state of the art, what is known and what is not known. 2. To be able to think "out of the box". 3. To be disciplined enough to concentrate on the tedium of a formal investigation of his wondrous speculations.

1. To know the state of the art. That's not genetic. You have to devote time to the reading and the learning. This is the second biggest problem with the speculation of amateurs, who may come up with a brilliant idea but suffer from self-doubt: "well, somebody must have already thought of this." Its corollary is accepting that what everyone knows is true, because better minds than yours have checked.

Herschel discovered Uranus, which had probably been observed by a billion people over 6 millennia. But he knew that everyone "knew" it was a star, so was able to ask a now obvious question: if it's a star, how come it gets visibly bigger when you magnify it, unlike all the other stars? Hello?

2. To be able to think "out of the box." This may be genetic, but I doubt it. More often it is the result of using one mode of thinking and training from an unrelated discipline. Not to call myself a genius, but if I was a grade focused pre-med, then med school, then residency guy, this blog and its ideas wouldn't exist. Herschel wasn't a mathematician or an astronomer; he was a professional musician. Not amateur musician- professional, as in that's how he earned his living. Raised by a professional oboist father, played oboe, cello and organ, composed 20+ symphonies, director of the Bath orchestra, etc. And then decided to discover Uranus. Sweet.

NB: age is also likely irrelevant. He discovered Uranus at 43. The infrared experiment was at 62. But most scientists, doing the same kind of thinking, year after year, are much more likely to get an endowed chair than make a novel discovery. (Interesting experiment: what if all Chairmen at Universities had to rotate disciplines for six months every five years? Can't be worse than what goes on today.)

3. Discipline and work. This would be the biggest problem with amateurs. Scientists have it in gigantic proportions, but often to the exclusion of free thinking and speculation.

Sure, it took Herschel half a second to ask, "what about the temperature in the dark zone?" but it misses how much work he put into his "amateur" investigations.

The old sayings "success is 1% inspiration, 99% perspiration" or "90% of anything is just showing up" really speak not to the necessity of work, but to the point that most ideas are mediocre and it doesn't matter. Diligent application can make almost anything a success.

===== ====== ===== The Last Psychiatrist: When Therapy Won't Work, Try Cymbalta. When Cymbalta Doesn't Work, You're Dead Meat

this should work as well as placebo

I.

A patient describes being told by her psychiatrist that her depression was too severe for therapy or behavioral techniques. Only medication would work. The patient says that the doc was right:

Her advice was grounded in neuroscience.
One research study... used high-definition brain imaging to reveal a breakdown in the emotional processing that impairs the depressive's ability to suppress negative emotions. In fact, the more effort that depressives put into reframing thoughts-the harder they tried to think positive-the more activation there was in the amygdala, regarded by neurobiologists as a person's "fear center." ... Healthy individuals putting more cognitive effort into [reframing the content] decreas[e] activity in the brain's emotional response centers. In the depressed individuals, you find the exact opposite.
Well, that's one interpretation. Another among the other fifty possible would be that depressive patients don't have an opposite response to cognitive framing, but that they are unable at that time to do it-- and so they end up using an emotional reframing, hence the amygdala effect. See? All depends what century you want to live in.

It's an easy criticism to make-- and I've made it-- that this kind of advice damages society, because it makes it acceptable, normalizes, that idea depression is primarily a biological illness that requires meds; and, in a more general way, that "health," emotional and physical, is just as much other people's problem as it is yours.

The title of that article is: Note To the Severely Depressed: Don't Try So Hard.

II.

"So you think that doctor sucks?"

No, actually she's a good doctor, and this is why robots will never be able to be (good) psychiatrists, though that they will become psychiatrists is inevitable. She (the doctor) looked at her, understood her, where she was in her life, and did what the Oracle did:

Neo: But the Oracle told me--

Morpheus: --she told you exactly what you needed to hear.

She tailors the advice to the whole patient, their perspective, their life, their situation. That's gold, that's the only reason the psychiatrist is there. The psychiatrist did the cognitive reframing for her. The post doesn't describe how awesome the Pristiq or Cymbalta was, it describes how awesome the advice was. Hearing the advice got her better, not taking the advice. Said another way: had she not internalized this advice, would the Cymbalta have worked?

III.

Before you ask me: no, I'm not advocating lying to patients. She wasn't lying, she was saying what was true at that moment for her patient.

"Until you feel stronger, I suggest you stay away from the type of self-help literature you have brought it because those texts can do further damage if read in a very depressed state." [said the psychiatrist]
The psychiatrist's advice to this patient was perfect; this advice to anyone in general with depression would be disastrous-- beyond it not even being accurate-- for them and for society.

Example: what if the medication doesn't work? You've already told them that CBT and yoga are no good for severe depression, so if the meds fail, does a person have any hope left? One might reasonably argue that the type of person who fails medications should try CBT or yoga.

Some people derive strength from knowing their symptoms aren't their "fault" and out of their hands; others derive strength from believing that it's entirely up to them, that they can overcome anything if they apply themselves. Each patient has to be evaluated separately, and their advice individualized. And, of course, all of this is in flux: in a month, they may have a different worldview. In psychiatry, if you burn a bridge, you're trapping the both of you on one side.

III.

We can ask one last important question about the utility of advice in medical treatment. "Said another way: had she not internalized this advice, would the Cymbalta have worked?"

Everyone knows that with every efficacious treatment, some proportion of it is related to a "placebo effect." For example, being told you are being given a strong pain killer (but it is a placebo) reduces pain by some amount. Similarly, while antidepressants reduce symptoms by 30%, placebo does it by 20%. So we atttribute some of the antidepressant's efficacy to the "placebo effect."

This is based on the patient knowing they are getting a medication or a placebo.

What happens when you are given a medication covertly? Not that they think it's a placebo but it's actually Valium, but rather that they are not aware they are injesting a chemical at all? Would taking valium but not knowing you are taking anything at all reduce the anxiety?

Not very reliably.

This doesn't imply you feel nothing; it means that your symptoms remain unchanged. e.g. "I suddenly feel more tired, but still anxious."

We tend to downplay the effect of words. An antidepressant has a chemical effect that is real (even if it might not be efficacious) but words are thought to be incidental. That's backwards.   Someone can make you cry with words, someone can make you sad forever with words. How a doctor frames your chances for improvement matters. And how, by the pitch of his voice and the choice of words, he conceptualizes your problems also matters a great deal. Ask David Foster Wallace.

---

(part 2, sort of)

Also see: Is Prayer Worse Than Cymbalta?

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===== ====== ===== The Last Psychiatrist: The Dumbest Economic Collapse In History

If nothing was ever going to be the same again, how come GS is back to where it started?

Anyone who sucks at poker knows: if you lose 50% on a bet, you have to go up 100% just to break even. Jamie Dimon is therefore the greatest poker player ever.

Of course I know Bear Stearns went under, I was watching TV when it happened. But we were all repeatedly told that it was never again going to be so easy for financial companies to make such huge money. The CEOs didn't deserve their big payoffs because they had lost so much of "the public's" money.   That was the point, right?   "We want clawbacks!" Claw what back?

Everywhere I look, I see that unless you lost your job, nothing has changed. Look closely at your life. Other than body fat, what's changed?

II.

Let's go corporate. Astra Zeneca is a good case study. What has been the longer term impact of the Crash?

Pretty much nothing. Except for the 15% cut in its workforce. A skeptical person might suggest that it was only able to improve its earnings not by selling more products but by cutting expenses. A finite and unsustainable maneuver. So sell AZ?

A more cynical person, though, might think that AZ simply used the "recession" as an excuse to lay people off, and get fewer workers to do more.

And a paranoid would think this: there's a popular idea that in a recession, the government should create jobs programs/public works projects. But what if it's the other way? What if the government had some projects it needed done?

And the business sector that it serves needs a reason to reduce their labor costs without people going 12 Monkeys on them.

There's a word for this, but I always get it wrong.

(IIb.

There's an analogy for the credit crisis that I am convinced is awesome: chemotherapy. Spread the poison liberally around the world. When you're done, you're weaker, but anything that had a high growth rate is dead. You've solved your Putin problem. Remember "we want a new reserve currency!" at $140 oil? U.S. to Putin: bite me.

"A rising tide lifts all boats." said JFK. But we're the only one with a boat, rickety as it may be. So let's Noah's Ark this bitch, and drown the lot of them. If they want aid later, we can pay them in Euros like they wanted.

That's how you solve a labor problem.

/sarcasm)

III.

Back to reality.

Remember how the crash was going to make people spend less, especially on frivolous things? Remember how the one single positive effect of the Great Crash was that the culture of the next generation would be less materialistic than their elders, the Dumbest Generation of Narcissists In The History Of The World?

If there was any company that under that hypothesis should have gone bankrupt, it is Duke University coed fraternity Aeropostale:

Explain to me how Aeropostale not only survives the crash, but actually grows? Don't say "pent up demand," I'll gut you. Look at the chart. Pent up for what, 3 months? Everyone suddenly needs last year's winter tops?

Is this pent up caffeine withdrawal? "$4.50 for a grande battery acid with skim? Let me have a blueberry dessicant as well. (I don't know why, but I'm like, so hungry today!)"

IV.

"Listen you insensitive jerk, people have lost their jobs, their homes, they can't feed their families--"

I'm insensitive, I don't have retinal cancer. I see what's happened to them, do you see what's happened to everyone else?

"Is the era of easy credit over?" recommended the AP two years ago.

"I think we're undergoing a fundamental shift from living on borrowed money to one where living within your means, saving and investing for the future, comes back into vogue," said Greg McBride, senior analyst at Bankrate.com. "This entire credit crunch is a wakeup call to anybody who was attempting to borrow their way to prosperity."
and

"We're going to see some fundamental changes in consumer behavior," said Frank Badillo of TNS Retail Forward, a consulting and market research firm

This is what "fundamental" looks like:

I'm pretty sure incomes aren't up since 2007. So either we have the same amount of money we had in 2007 and are spending the same, or we have less than 2007 and are spending more. Either way: really?

Get it? Double the unemployment, same sales. While some people aren't "participating in society" the rest of you have made up for it, and then some.

m=1? "Sorry about the delay, next stop 80"?

Housing prices have fallen, but they have also stopped falling. Maybe they're not going up, but if you still have your house... you're home free?

If you took two Ambiens in 2007 and just climbed out of your bathtub now, here's what you'd feel required a remark: "oh, they're ending Lost."

V.

You'll say I'm selective in my charts. "Put up Citigroup!" Fair enough; but my point here is that we were supposedly in for a systemic, historic, and permanently altered economic landscape, and we're right back where we were started.

That's Moral Hazard, and I capitalize it because you should, too. What have we learned? Nothing. What's changed? Nothing. What are we going to do now? Buy a car. "With what money?" Zark off, man, you're harshing my buzz.

(Economist:) The recession came at the end of a period marked by record levels of inequality. Many Americans, lacking true upward mobility, bought its trappings, such as a bigger house or better car. Disaster duly followed.

Is there any reason to think this scenario isn't worse now, more likely to be repeated? While some people worry about inflation, and others about a double dip recession, what's actually happened is that we're back in the same boom/bust cycle.

Of course I understand that the various government actions have helped. That's the point.    There is nothing that will prevent this from happening again. I don't want the Crash to have been worse, but I don't want it to have happened in the first place. It did. Now it's going to happen again. It is inevitable. Maybe not in my lifetime, but definitely in my kids'. Isn't that worse?

Of course I understand that CEOs are corrupt and Bush lied and [random Huffington Post link here]. Enough, I get it.

But have you changed? Doing anything differently?   Instead of buying yet another identity signal, have you saved the money for the kid you don't even have yet? Blame the CEOs if you want, they don't shop at Aeropostale and if they do they can afford it. So?

The problem and solution is you. It has to start with you. It is always you.

---
http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: The Dumbest Generation Is Only The Second Dumbest Generation
You know that 17 year old kid who thinks Obama is Muslim and Europe is a country and any girl that doesn't sleep with him is a slut? I found someone dumber than him. Wasn't hard, either.

The Atlantic asks, Is Google Making Us Stupid? Just asking: could the real culprit be The Atlantic?

Nicholas Carr says Google is, because along with the massiveness of the available information comes an avoidance-- or simply lack of time-- for contemplation and concentration. Or, to borrow a metaphor (I can't remember who said it) such knowledge is a "mile wide and an inch deep." Oh, Artemus Ward said it about the Platte River. Thanks Google, I feel smarter.

Carr also finds he is less able to read deeply, to concentrate; and he can't read novels anymore. It's changed not just what he knows, but how he thinks. He thinks in internet-style.

I'll generalize: it has changed how most people think.

II.

The effect on medicine is noted by Carr, and by me: doctors almost never read an entire article, and rarely even abstracts. Title, keywords, or title/keywords of shorter summaries written by someone else.

In Science appears Electronic Publication and the Narrowing of Science and Scholarship, in which a now not surprising finding is revealed: the more articles are available online, the less they are read. It also shifts the age of the cited articles up to the past ten months. Recent reviews get read; original studies don't, even to verify the claims. Anything in science that's not "hot" now won't even get read. It's groupthink reinforced by a research diameter of 2 years.

Electronic subscriptions means even less awareness of the contents. At least when you got the print journal, you flipped through it.

If you want to know why doctors seem always to be hashing the same ground, it's because they are.

III.

As I've noted elsewhere, there are two important effects:

1. As Socrates said, people become "filled with the conceit of wisdom instead of real wisdom" (e.g. Artemus Ward?)
2. you really only know what someone else wants you to know

But there's an another effect, and it has to do with the medium.

Nicholas Carr writes that Nietzsche (title of this blog, BTW) stopped writing because of eyestrain-- until he bought a typewriter and learned to touch type with his eyes closed.   His style changed; his already tight prose got tighter. Nietzsche himself noted it, and quickly gave up on it; and, according to Carr, a later scholar observed that the writing "changed from arguments to aphorisms, from thoughts to puns, from rhetoric to telegram style."

Anyone who writes for a living understands this; Neal Stephenson (Anathem) writes with a fountain pen; I can only write on a computer. But-- and you should try this-- using any other medium makes one think differently. I have used this technique to generate new ideas; my post on The Wrong Lessons of Iraq and the other on We Are All Mercantilists Now were both generated on my Blackberry. It felt immediate, important, urgent, political. I could never have written the Wanted humor piece that way. I couldn't have even conceived it. It was part me, part Movable Type.

So the internet allows the delusion that you know things that you really don't; the mistake that the thoughts you do have are your own, and not someone else's; and then changes the way you think, reinforcing this style of thinking.

IV.

Enter Mark Bauerlein's The Dumbest Generation: How The Digital Age Stupefies Young Americans and Jeopardizes Our Future (or Don't Trust Anyone Under 30). Bottom line: kids today have (access to) lots of information, but no wisdom. And, rather than the internet bringing diverse people together, it seems to foster tribes of the like-minded, who never closely examine anything different(ly).

We don't know much, and we stick to those who who are like us, who provide our much needed affirmation.    If that's not a recipe for narcissism, I don't know what is.

V.

Sounds much like the book by former assistant secretary of education Charles Finn, with Diane Ravitch, What Do Our 17 Year Olds Know? You can guess the answer. 8000 seventeen year olds: half thought he book 1984 is about the end of the human race in a nuclear war; 35% didn't know Watergate was after 1950. 30% didn't know Aesop wrote fables. They thought Jim Crow laws were good for blacks. Etc.

Except it isn't all their fault. Kids are only as dumb as they're allowed to be. Here's an example: introductory "survey" courses in state colleges are universally accepted to be a joke.   But why not simply change that? You can still keep the grade inflation and "everyone passes" ideology; but why not just have a professor who cares with rigorous content? Well, because he doesn't care, and the school doesn't care. They have other things to worry about then oversexed freshmen. So how can you blame students for not knowing anything? The college does not even allow them an opportunity for knowledge that they could lazily opt out of. The system offers only no knowledge.

VI.

"Kids today" may be the Dumbest Generation, but the parents and teachers of the Dumbest Generation are themselves so dumb they not only don't know the information themselves, they don't even know what knowledge exists that is important to pass on.

And I can prove it: the above book What Do Our 17 Year Olds Know? was written in 1987.   Those dumb 17 year olds are 40 now.   Say what you want about the "elitist" conclusions of The Closing of the American Mind but it was also written in 1987, about 1987 college kids-- who are now adults.

The adults are dumb, all right; but they don't know it. They have a unsettling feeling that something is lacking. The general narcissism and insecurity of parents today-- even/especially the "good" parents, is visible in their parenting. At a birthday party, the kids are running Lord of The Flies while their parents completely ignore them, socializing; meanwhile, they hover over them at the store, at the playground-- "no bicycle without a helmet." They secretly read their kid's email and Facebook accounts, but have never once read the kid's math book. "Oh, ha ha, I don't remember all that math!" Idiot, could you at least pretend it's important?

If you do your kid's math homework with them every night, I swear to you that you won't need to worry about Facebook. I will concede that monitoring their Facebook is easier.

Many professional parents and teachers I know fall back on empty words-- "classical education" or "the use of primary texts" but they don't know what those terms mean. They nod respectfully at Aeschylus, but they don't have the first clue whether he fought for the Greeks or the Trojans. You think these parents and teachers are going to know to tell the kids to read Werner Jaeger?   They're not. They're going to buy them a Leapster.

VII.

Simply put: adults today don't know what's important to know. So they make things up to care about.

No one won the culture wars; we forgot who the enemy was. In 1987, when Allan Bloom or William Ayers argued for or against a "classical" education, they were arguing its importance, not the definition. Now? That's why there is so much noise about school vouchers for private schools-- it's a proxy for the culture war without having to know exactly what you're fighting for. There is a vague feeling that private schools are "better," that the surrounding students are "better," that it is more "rigorous," without really knowing what they are pushing towards or away from. It is also evident that it is a fall back; it makes up for their own shortcomings. Secretly: "Hopefully a good school will teach them better than I can." Well, you'd be right on that point, anyway.

I'm not advocating a "return to the classics" (I'm not not advocating it either), but I am observing that the Dumbest Generation of Narcissists In The History of The World is not even remotely conscious of their ignorance or their narcissism, and the technology lets them get away with it-- they actually think they think they know, they actually believe they have chosen what they think is important. And they are now parents and teachers and doctors and leaders. As far as I can tell, this simultaneous conjunction of ignorance and unconsciousness has never happened before in history.

I have every hope and faith in the youth of today, because otherwise we are doomed.

"Don't trust anyone over 30" turns out, after all, to be very sound advice.

----------

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===== ====== ===== The Last Psychiatrist: The Enemies Of Promise Guard The Road To Success
Those enemies would be you yourself.

I.

This is how Malcolm Gladwell, author of The Tipping Point and Damn Right I Only Use A Mac, opens his The New Yorker piece on the different types of genius:

Ben Fountain was an associate in the real-estate practice at the Dallas offices of Akin, Gump, Strauss, Hauer & Feld, just a few years out of law school, when he decided he wanted to write fiction....He decided to quit his job....He made a plan. Every day, he would write until lunchtime. Then he would lie down on the floor for twenty minutes to rest his mind. Then he would return to work for a few more hours...
In this fashion, this young talent wrote a book which got a great review in the Times, won awards, etc. But as inspirational as this "quit your job and become a writer" story sounds, for Gladwell, the punchline is this:

But Ben Fountain's success was far from sudden. He quit his job at Akin, Gump in 1988. For every story he published in those early years, he had at least thirty rejections...His breakthrough with "Brief Encounters" came in 2006, eighteen years after he first sat down to write at his kitchen table. The "young" writer from the provinces took the literary world by storm at the age of forty-eight.

Gladwell goes on to describe the two kinds of genius or creativity. The first, in the young, is conceptual. These people have a nearly fully formed vision in their minds that simply needs to be transformed into material reality. The other, in late-bloomers, is experimental. They're not sure what they're getting at, they have multiple iterations, and then suddenly/finally they're onto something.

He uses many such pairs of examples (e.g. Cezanne and Picasso.) The anecdote he tells at the beginning, the "quit your job as a lawyer and become a writer" depends on the latter type of genius/creativity.

II.

Right off the bat, I have a question. How come no one ever thinks a person a genius if they quit their job as a writer to become a lawyer? In fact, that's always considered selling out. Before you laugh, consider that it is actually harder to do this then to go in the other direction. "The world doesn't need another lawyer" is probably a popular answer, but I submit the world doesn't need another Ben Fountain, let alone the thousands of Ben Fountains who have quit their jobs and never finished their novels. Why does our culture place a higher value on mediocre art that will never survive ten years then on a lifetime of grinding out the parts of the engine of society? And if/since creative art is so valued, why don't they get paid more then the grinders?

III.

Gladwell is perfect for those who want still to believe they can be anything they want, even as they drive 45 minutes each way to the place of their slow suicide.

I'm a fan of Gladwell too-- how can you not be? He is compelling, fascinating, every sentence seems to have an implied exclamation mark, and for anyone under 50 who still has hope they'll "do something" with their lives his books read like revelations, they make you feel as if he's figured out the essential ingredients to success. Wanna be CEO of a major corporation? Knuckle pushups. It's all so obvious, so easy. And yet, here I sit...

An example here is illustrative. He compares Bill Gates of Microsoft to Bill Joy (who looks like Gladwell) of Sun Corporation to show how they achieved their success. You'll notice they are both Bills. That's not incidental to the comparison, it's the entire pretext for the comparison: "These two Bills are similar because..." The "Bill" becomes a shorthand for the other similarities (10000 hours of work, etc). But just as the "Bill" itself gives you nothing useful to work with, neither do any of Gladwell's conclusions. "One of the reasons Heidi Montag and Heidi Klum are so attractive to men is that they have big boobs." Ok, so now what? Will either a name change or plastic surgery really make me look like them?

Essentially-- and I mean this with no disrespect or ill will, again, please remember that I do very much enjoy his books-- they are a waste of time. You walk away thinking you learned something, thinking you have a new perspective, but you don't. If you doubt this, try to summarize one of his books in a sentence and see what you get. Here's The Economist:

Mr Gladwell finds that being in the right place at the right time, having the right antecedents (affluent, caring parents are a big help) and seizing the chance to get in lots of practice (he calls it the 10,000-hour rule) are all as critical to success as raw talent.

Outstanding. Do you want fries with that?

IV.
In contrast to this, to this approach "what makes a man succeed?" which is answered with "lots of things you have very little ability to replicate, so just get to work" it may be better to ask, "what makes a man fail?" and at least avoid those things.

Enemies of Promise is a book in two parts (one third and the other two thirds). Part 2 can be appropriately called: I, Cyril Connolly, a man of considerable education and insight, have been unable to write the literary masterpiece that was assumed to be in me, so instead I am writing a book about why I was unable to write such a book.    Anyone who hopes to accomplish anything artistic, or anything of merit, would do well to stop everything else they are doing-- or not doing-- and read Part 2.

No summary does it justice. I am only going to mention key reasons I think immediately applicable-- and changeable, in the hope it inspires you to read it yourself.

Day-dreaming and conversation: "These harmless activities are more insidious [than drink and opium.].... Daydreaming bears a specious resemblance to the workings of the creative imagination. It is in fact a substitute for it... This is even more true of conversation; a good talker can talk away the substance of twenty books in as many evenings... He will describe the central idea of the book he means to write until it revolts him."

Less talk, more write. No one should ever know you are writing a book, and it's content should not be able to be inferred from past conversations.

Journalism: For want of money and immediate gratification, the talented author may turn to... blogging. "By degrees the flippancy of journalism will become a habit and the pleasure of being paid on the nail and more especially being praised on the nail, grow indispensable....

Promise: "...the burden of the oath under which we grew up becomes the burden of expectation we can never fulfill....Occasionally they win and the load of other people's wish-fulfillments is cast off; they produce a book; more often after a struggle for breath they are stifled forever."

Admiration and criticism: "Butler said an author should write only for people between 20 and 30 as nobody read or changed their opinion after that. Those are the years when the artists are promising and the admirers full of admiration; by the time the artist has ceased to be promising and become a good writer, the admirer is a critic whose judgments are flavoured by his own self-hatred or who, taking the author as a symbol of his own youth, refers all his later books back to his earliest. When an admirer says, "Ah, yes! But if only he would write another Prufrock!" he means, "If only I was as young as when I first read Prufrock." The sour smell of the early thirties hangs over most literary controversy."

(Not old) Age: "The shock, for an intelligent writer, of discovering for the first time that there are people younger than himself who think him stupid is severe... It would seem that genius is of two kinds, one which blazes up in youth and dies down, while the other matures, through long choosing, putting out new branches every seven years. The artist has to decide on the nature of his own or he may find himself exhausted by the sprint of youth and unfitted for the marathon of middle age. A great many writers die between those years... commit suicide; others succumb to pneumonia or drink or have nervous breakdowns...

"Solvency is an essential." "...otherwise he must become a popular success or be miserable."

Privilege: "It is the theory that the experiences undergone by boys at the great public schools, their glories and disappointments, are so intense as to dominate their lives and to arrest their development. From these it results that the greater part of the ruling class remains adolescent, school-minded, self-conscious, cowardly... Early laurels weigh like lead and of many of the boys whom I knew at Eton, I can say that their lives are over."

Etc. Now get back to work.

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===== ====== ===== The Last Psychiatrist: The Extent Of Psychiatric Knowledge

The answer:

Answer: Irritability tends to be more prominent
In mania, classic DSM-IV symptoms, such as changes in sleep and appetite and racing thoughts, occur in children, adolescents, and adults. The key developmental difference between youth and adults is that in the presentation of mania, irritability is more prominent.

This is an example of how a) psychiatry has lost its way; b) multiple choice questions are useless.

First, the context of the bipolar question is a CME quiz based on an article: pass the quiz, get CME credits, which the State Board requires doctors to get. I don't have to take this quiz; but this quiz is accredited as a legitimate means of getting CME, i.e. it is educational.

What multiple choice questions test is synthetic judgments. It tests, "what is the universe like, actually?"

---

An analytic proposition is definitional; a synthetic proposition connects two independent parts that are not contained within one another.

A synthetic truth is one which its opposite can be conceived. The opposite of an analytic truth is illogical. So "humans have one head" is synthetic; "humans" and "head" are independent parts, connected. It's possible humans might have two heads, or none. "Bald men have no hair" is analytic. "Bald" means "no hair."

The sentence, "adult AML has higher lethality than childhood AML" is synthetic because "AML" means something concrete that does not contain the notion of higher lethality in adults vs. kids. "AML has more myelocytes than lymphocytes" is analytic because myelocyte perdominance is contained within the definition of AML.

Saying childhood bipolar has more irritability than adult bipolar isn't synthetic; it isn't additional information about "bipolar." It is the definition of childhood bipolar.

-----------

Consider the relationship "if p then q." Therefore, if not q, then not p (contrapositive.)

So which is it:

"If you see X symptoms, it's bipolar."

or:

"If it's bipolar, he has X symptoms."

?

----

"If he has X symptoms, then he has bipolar" is logically equivalent to "If he is not bipolar, then he does not have X symptoms."

Or:

"If he has bipolar, then he has X symptoms" is logically equivalent to "If he does not have X symptoms, then he does not have bipolar."

It's obvious that both pairs of statements are invalid, because on the one hand we are agreeing to label a collection of symptoms as "bipolar" (analytic), but on the other hand we are secretly allowing that we can intuit "bipolar" regardless of a previously agreed upon definition, i.e. the symptoms (synthetic).

Cleverly, we allow ourselves another opening: use the definition to make analytic judgments (he has bipolar therefore he will have manias) and use our experience to make synthetic judgments which alter to the definition (manias may indeed be absent, replaced by irritability), simultaneously.

And we do this because the real meaning of the term isn't what is meant by it, but how we intend to use it.

--------------------

"If we had to name anything, we should have to say that it was its use." When a mathematician sees something that resembles "irritability" what does he call it? But when a psychiatrist sees something that resembles "irritability," what could he call it? The mathematician finds the dictionary word "irritability" quite suitable for his purposes; but the psychiatrist can do nothing with the word "irritable" except use it to imply something else.

The sly move is to consider "irritability" to be a modifier of the more general construct "bipolar." But "bipolar"is actually the modifier of irritability.

---------

Maybe you are confused, because your mind is stuck on viewing bipolar as a term independent of the agent who observes it; a term that we learn things ABOUT. But the meaning of "bipolar" is recursive.

It's pornography, impossible to define except as "I know it when I see it." But that statement does not mean pornography is "very hard to define, but easy to identify." It means it is defined, ad lib, by me.

Synthetic propositions can be learned to be true (or false): "the majority of married men are happier than the majority of single men." But what can be learned about pornography that is independent of the one experiencing pornography? "The majority of pornography depicts nudity." Even the word "majority" is useless since it qualifies a word which is itself a personal judgment.   This is neither a true nor false statement; while I know what "nudity" is, we still don't know what pornography is except that you are now defining it as containing nudity. But once you choose a definition, can you change it? Well-- what about a magazine devoted to stocking fetishists that has no nudity-- indeed, possibly no actual people?   Statements about pornography can not be found true or false because the term pornography requires an active subject. It isn't a noun, it is a judgment about its use.

You mean "community standards." No-- a nude woman in Playboy is "porn--" but the exact same photo in a Soho art gallery seen by the same people may be something else.

"But we all agree, at least, that certain things are pornographic." But a consensus among individuals isn't truth, it's definition: "we agree to call this pornography." Until, of course, someone disagrees. But what is the basis of the disagreement? It is never content, it is always intent: pornography is that which is "intended to elicit sexual arousal." We disagree about what the purpose of the images are.

--------

What is the intention of the diagnosis "bipolar?" To describe something?    As a reason for something? To imply treatment?

"But you have to agree that if I give a child with bipolar disorder bipolar meds, they get less irritable." But why not call them "irritability" meds? If you gave them to an irritable child without bipolar, would they not get less irritable? Or is it that if you gave them to an irritable child and nothing happened, the child doesn't have bipolar?

"I have a map of an imaginary world in my mind; according to it, you should be able to get to my house in twenty minutes." The map exists for him, but tells you nothing about the real state of affairs. And can you rely on such a person to use the term "minutes" the way you expect?

The term "bipolar"-- whether it exists (as a so far unknown physical pathology) or not-- isn't valid because it says nothing about the world; it only says what the person using it thinks about the world.

===== ====== ===== The Last Psychiatrist: The Fall And Rise Of Rebecca Black

agreed: bomb Libya

For those of you without an internet connection, Rebecca Black is the 13 year old nobody pretending to be a 17 year old nobody who wrote a song and made a video that everyone hated almost instantly. But haters gonna hate, yo.

Even Autotune couldn't repair her nasally, off key voice. But, and but, is it the worst song ever? Is it worth 30M hits of venom and disgust?

Break it down by parts and look at them. Music? Off the rack pop music, indistinguishable from anything else. Lyrics? Probably below average, but no worse than "la la la la la la la" which is Kylie or Dannii Minogue, depending on the decade you last ejaculated. Singing? Again, below average but worse than Ke$ha or the entire Colbie Caillat portfolio? Shut your mouth.

Video? Standard illogical mandness, why is a 13 year old girl going to a party like she's been doing it for years? Is she an emancipated minor? No one can say, but does it make any less sense than the Black Eyed Peas having a dance off to a song they didn't write and have no business sampling? Unlike that video, when I watched "Friday" it never crossed my mind how urgently the video needed a speeding box truck and an oil slick.

No. None of the parts adequately explain the level of hate. And that's because the hate isn't directed at any of the parts, or at the video, or even at her, but at what she represents: another spoiled rich white girl that has a video made for her, and releases it like she's as good as her Daddy's money pretends she is.

II.

No, no judgmental statements from me, not yet, I am merely giving substance to that hatred so you can understand the rest.

No one hates Rebecca Black for her music, you hate her because she's spoiled, because she has opportunities in excess of her talent and the ability to create what superior artists will never be able to simply because they lack the economic resources or maybe even the free time that Rebecca has plenty o'. It's hard to get to the studio when you've got an 8am down at the main office. Welcome to America, no one said it would be fair, in fact, no one said a damn thing at all, they just showed you the pictures on the TV commercials and we inferred the rest. Meanwhile, no one's yet recognized your talent. Rebecca's Dad forced us to recognize hers, and she wins even by losing, but he's one guy. Are you so angry at this one guy who gamed the system?

If it was just another battle in the Class War, so be it, another perfect proxy for our fury is sure to get upmoded on Reddit so save some energy for later.

But then something happened: Rebecca announced on Tuesday's Tonight Show that she was giving the proceeds from the video to charity, to Japan relief funds. Well, you might say, she may suck and she may be spoiled but at least she thinks about things bigger than herself and for a 13 yo that's not bad. And just like that, the tide turned, the haters slowly became challenged by the respecters? defenders? enablers? and comment after comment, blog after blog, article after article, her selflessness overshadowed her posited lack of talent and now...

Slow down.

The problem with that narrative is it doesn't match the calendar or the numbers. Even as of now, haters trump respecters 10 to 1, though admittedly it's changing. And the support for her predates the Tonight Show appearance-- e.g. Lady Gaga calling her a genius, Alan Colmes stating "she has a wonderful voice."

The tide didn't turn because she gave the money to charity, the tide turned because it hit critical mass where it was no longer cool, no longer original, no longer branding, to hate her; it was cooler to like her.   None of that has anything to do with Rebecca Black-- did she remaster the audio? get implants?-- it has to do with how we form opinions in the age where instantency matters more than consistency, let alone logic. That's right, I invent words.

That's America, that's how debate is done in America, that's how we decide all of our questions from who blows as a singer to which blathering dictator we should oppose/depose/impose. We don't have beliefs, we don't have positions, we have reactions to other people's beliefs, to other people's positions. As long as you can be shown to be a free thinker opposing the tyranny of the majority's insightlessness then you can look like a hero, and if you have to pull a 180 in a week or so to do it, party on. No one will care/remember what you did last party. Just remember the rule of opinion, of media: speak early, and often, and if you have to drag a 13 year old down or dramatically alter foreign policy for the next quarter century to lift yourself up, hey, it's all good.

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===== ====== ===== The Last Psychiatrist: The Father That Shot His Daughter's Computer

it succeeded

I. "I'd love for you to write about the dad who shot his daughter's computer because she posted something nasty on Facebook. "

This one's easy. He's insane. How do you work in IT but it takes you hours, let alone hundreds of dollars, to upgrade a laptop? Doesn't he know you just pick up an unattended one at Starbucks? I got a MacBook Pro with a OccupyMyPants bumber sticker on it. Sweet.

He's the Dad, he's held to a higher standard. What was his intention? To change her behavior? But there were a million ways he could have done this, including reading that letter and shooting that laptop in front of her and not in front of other people. Would he have dared? But the very point of the operation was the video.

The mistake is thinking that he was trying to shame her into improving. That never works, it simply reinforces that outward appearances matter more than what's true, which not coincidentally is the very purpose of facebook.

But never mind that, look carefully at what Cat-5 Tex revealed about her that was so shameful: nothing. She never appeared in the video. Her terrible facebook post that he read was already on facebook for all to see, we learned nothing new about her, all the information we learned was about him. He was repairing his own image as the kind of father who'd have the kind of daughter who'd do this-- this being not her goddam behavior (after all, he had lived with her and her goddam behavior a goodly number of years without incident) but her publicizing her behavior. He was shamed not by her behavior but Facebook revealing it, which is why Facebook had to die. If he was Muslim they'd have called it an honor killing.

Is she going to change? Not likely, and it's not evident what about her needs to change except her address. No, I don't mean she has to flee, I mean she has to grow up, so does he, both of the dummies involved violated one of the cardinal rules of family: don't disparage someone in the family to someone outside the family. If you need me to explain this you are a terrible person.

II. Uh oh, why is there a II?

Here is a thought experiment: how would you feel if you found out this video was a hoax?

Why were you so passionate about the video? Now that time's passed, it hardly seems like it was worth the energy. But at the time it was urgent that you expressed either one of the two approved opinions:

"Kids today are so goddam spoiled. When I was their age I had to work, now all they do is play video games..."

Who bought them the video game? What did you think they were going to do with it? Trade it for a calculus tutor?

Who spoils them? Maybe you're not to blame if they turn to meth, but who else could be to blame if they're spoiled?

"The problem with kids today..." Stop right there, I'll finish: is parents today. Parents today suck.   I've checked. The Illuminati let me see the CCTV from every American household and in all of them everyone is in separate rooms staring at a glowing lie.

Do you have a child who is like that guy's daughter? Then you're an idiot, not for having such a child but for diverting energy to support of that guy, in the same way that the reason your wife left you is the porn. It's not the from-behind action, it's the neglect. I know you are not going to believe this, but the reason your child is trouble is that you support that man.     "I don't understand kids today." Tell me if I'm close: "You need to study to go to college, major in business, get a job working for a salary and if something goes wrong let the government you hate so much cover your medical, disability, and retirement needs. Saturdays are for yard work. Sundays are for church and football." Sound right? Kinda surprising that they'd want a different future, and that's why your kid smokes weed but calls it pot.

"That father is a narcissistic jerk!"

Why so serious? Think about how little rage you feel for the 99% prevalence of incest in an inner city. Let me check your facebook, see if that sexual abuse didn't prompt an all caps comment. Hmm. No. "I'm not that angry about the dad..." Rage isn't about quantity, but about certainty.

"So I can't have an opinion about this?" Of course you can, there's value in that and you've discussed this video with lots of people, I'm sure. Did you discuss this with your parents or your kid? That should have been your first thought. Did you sit your Dad or your Mom or your 15 year old down and say, "I'm going to show you something and I want you to honestly tell me your thoughts, random, unfiltered, and I swear to you I will treat you like a human being and listen and not get defensive and angry like I always do every time we talk about something that reveals you to be something other than what I see in you." Because that would be an illuminating conversation.

This is the point: it didn't occur to you to do this. It occurred to you to voice your opinion publicly to anonymous strangers, but not directly to people that matter. That's what you've been trained to do, that's where your priorities have been taught to be. That's the Matrix. You're not thinking about your child's development, you're being tricked into thinking about your identity while the system uses you as a battery. No Red Pill for you. And no Red Pill for your kids, either.

III.

How do you think you came across this enraging video of a red state psychopath with a .45 and .NET certification? If you're watching it, it's for you.

How do you think you found this video of a decent Father resisting the AP Obama Studies his disrespectful daughter learned in those liberal public schools? If you're watching it, it's for you.

It's not completely your fault. The system is much bigger than you, it is a spirit; and you think you stand defensively because you were taught to think that the deep insight is that it's selling to you, telling you what to love or what to hate when it is actually telling you how to love and how to hate, not what to be but how to be. It nudges you towards the binary extremes so it is easier to control you. It wants you to have opinions, it wants you to "pick sides", "get involved", "take a stand." It doesn't want you to be indifferent, it wants you to love or to hate, rage or lust, so you feel alive-- but always your strongest passions focused on the irrelevant. "That Dad is awesome!" Then you'll vote Romney and the system has won, not because it wants Romney but because it wants to minimize your political involvement to voting. That shows you care; and if you really care you'd vote in local elections, too; and for the really active among you, why not donate your time to the campaigns? Grass roots! But the only thing that comes from grass roots is grass, and it doesn't really need your help. It just needs you not to have the time to consider planting something else.

-------------

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===== ====== ===== The Last Psychiatrist: The FDA Says No Black Box Needed On Drugs That Increase Suicidality, But Still Needed For Those That Don't

Yes, you read that right. Drink a big glass of OJ and put away your blotter paper, you won't need 'em in here.

In a metanalysis of 199 studies covering 11 antiepileptics, the odds ration for suicidality was 1.80.

The first question that the committee had to decide was whether or not it agreed with the agency's overall finding of an increase in suicidality for the 11 AEDs that were analyzed.

The advisory committee, after much debate, determined unanimously, apart from 1 abstention, that yes, there is a signal that is statistically reliable.
Forget about whether these results are accurate or useful. Just follow their logic: they believe their data.
The second question asked whether...the findings of increased suicidality should apply to all drugs included in the analyses, despite the observation that the estimate for the odds ratio for 3 of the drugs was below 1.
Remember science? Remember classism? Remember not blaming everyone in a group for the behavior of a few? If the odds ratio is below one, then it doesn't have the risk.
The committee strongly agreed that the findings should apply to all drugs.
Awesome. Faith in egalitarianism and the supremacy of science restored.
Well, all right, D- for interpretation of science. They want to believe it causes suicide, so be it.
After this discussion, the committee members voted strongly against a black-box warning.
But I thought you guys said--?
One committee member pointed out the potential "hysteric reaction" that can accompany a black-box warning about suicidality. Other speakers emphasized the need to balance efficacy vs harm and commented that "in two-thirds of the trials this warning is irrelevant," "a black-box warning has a very negative connotation," and "the number needed to harm was 2 per 1000."
But then how do you possibly justify taking the box off drugs that show an increased risk, but leave the black box on drugs that have no such data? Why does Seroquel get the warning-- no actual risk of suicide ever found, despite looking-- but antiepileptics don't, and they do have the data?
Other speakers also cautioned about diluting the effect of such a warning by widely implementing it.
Where's that rum? Goddamn it, Mary, where'd you hide my rum?

---

Resulting in the inevitable.

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===== ====== ===== The Last Psychiatrist: The Fed's Dilemma: The Moral Hazard

So the Fed has an interesting problem: whatever it does-- raise rates, cut rates, etc-- it causes a Moral Hazard, but to different people. To whom does it want to teach the wrong lesson?
Or, choose: rich get decimated, poor get poorer; or rich get richer, poor get by?

This is part 3-- click for Parts 1 and 2)

So the Moral Hazard for the Fed is that by cutting rates, it lets the hedge funds know that they will always be bailed out, that losses will always be contained. So go ahead, take more risks.

If that was all there was to it, the story would be boring. But there’s more.

Let me state explicitly that the mess we’re in is exclusively due to too much, too easy, credit. In order to have prevented this, rates should have been higher, but to raise them now—when no one can pay anything back—would be death. So rates either must at least remain the same, or get cut.

Here's the problem:
If they don't cut rates, many lose their homes; some hedge funds go under; some franchises, that borrowed money to open their stores, go under; people lose their jobs; so there's less money in the system, and we get a recession. Divorce inevitably follows. But note clearly that while everyone loses in this scenario, the poor get hurt much more than the rich do. (This is why it is a political certainty that they will cut rates, at least four times, before Nov. 2008.)
If the Fed cuts rates, we get a bailout-- people keep their homes, hedge funds don't go under-- but the the rich get richer while the poor simply don't get poorer. Even the thought of rate cuts has pushed the prices of most stocks back to the levels they were before the correction. They will only go higher from here. In fact, the Moral Hazard here is that hedge funds learn that they'll always get a bailout, so they take even greater risks for greater profits. But your house doesn't increase in value, it just doesn't melt in the snow. Asset prices and profits increase; wages don't. The gap between rich and poor expands.
This is complicated by a point so obvious that it is never mentioned: rich and poor are experiencing two entirely different economies-- one with inflation, and the other in recession.
Here's an example of this wealth gap. One metric the Fed used to measure inflaiton is the Consumer Price Index, which is an aggregate of prices across sectors: food, energy, clothes, etc. But in the past few years, the important metric has been the CPI omitting food and energy prices, because, supposedly, food and energy prices fluctuate wildly and thus are not stable enough to measure inflation. Have you seen the price of oil for the past 6 years? Does it look like its fluctuating wildly, or just staying high? So whereas the CPI shows prices overall have risen, the CPI "ex food and energy" incorrectly shows prices relatively stable, because it omits the two main sectors that show inflation.
The rich don't "see" increased energy prices. (Are their fewer SUVs on the road?) They see credit tightening.   They see their asset prices falling. They see "growth" declining. That's recessionary. They want a rate cut. But if you get a rate cut, prices go up.
What do you do if you're poor, and you have less money, but prices are on the rise? You go see a psychiatrist, that's what.
It's a tricky situation, so I'll summarize it here: prices have been rising, if you look at all prices. So rates should have been higher. Had they been higher, people-- everyone-- would not have borrowed so much, so poor wouldn't be seduced by low rate mortgages, and rich wouldn't have leveraged credit to bid up asset prices (including real estate.)
But at this second, everyone needs a rate cut, because everyone "sees" a serious deflationary pressure. (If your biggest asset is your house, and its worth 3/4 what it was a year ago, that's deflationary.) The result of this rate cut will be that the existing inflation, heretofore ignored by everyone, will be magnified. So while the poor will not have more money (they'll simply not have less), the rich will get much richer. Inflationary pressures will be much better handled by the rich, for obvious reasons.
And so the Moral Hazard. The Moral Hazard for the Fed is that by bailing us out-- and they will-- easy credit and the Bernanke put will worsen the cycle. And so the Fed plays a game, a stupid game but what else can it do? It orders rate cuts on key market days (options expirations) only days after it pretends it is worried about inflation; random Fed robots utter conflicting statements about the health or malaise of the economy-- all in an attempt to make it appear as though the inevitable rate cut is going to be canceled. It's all about the Moral Hazard.
But the game can backfire: if markets anticipate this is a game-- if they are sure there will be a rate cut, and they rise (Bank of America bought a stake in Countrywide, that's how sure of a bailout they are) then there's no need for a rate cut after all. Which causes markets to fall...
But it's the wealth gap that we should be worried about, soon to be greatly increased. Wealth gaps mean feudalism. They mean, on the one hand, universal healthcare-- everyone gets the same; on the other hand, flow chart medicine-- since everyone gets the same, let's just make a flowchart.
It also means mental health parity, which is really a way to funnel the poor into the only outlet we have to deal with their rage: psychiatry.
(Part 4 tomorrow)
(Long BAC)

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===== ====== ===== The Last Psychiatrist: The Fort Hood Shooter: A News Quiz

in which the better you score, the worse off you are

"so it was the Zoloft?"

I.

New York Times
MSNBC
NPR
Washington Times (NB: this is not the same as the Washington Post)
Fox News

Which news outlet published the following stories? (Hint: What do the titles say, and what don't they say?)

Nov 5: Army Doctor Held in Ft. Hood Rampage

Nov 6: 'Good doctor' stressed out by deployment?

Nov 6: Army: Suspect said "Allahu Akbar" before firing

Nov. 6: Fellow Worshipers Describe Fort Hood Shooting Suspect as Devout Muslim, Troubled By Wars

Nov 6: Obama: "Don't Jump To Conclusions" on Fort Hood Shooting

Nov 7 George W. Bush Visits Fort Hood, Wounded Soldiers

Nov 7 George W. Bush Secretly Visits Fort Hood Victims

(NB: these are two different articles.)

Nov 7: Little Evidence of Terror Plot In Base Killings

Nov 7: Suspect Was 'Mortified' About Deployment

Nov. 7: Suspected Fort Hood Shooter Was "Calm" During Massacre, May Have Shouted "God Is Great!"

Nov. 7: Uncle: Fort Hood Suspect Loved US

Nov 8 A Doctor, And A Conflicted Soldier

Nov 11: Walter Reed Officials Asked: Was Hasan Psychotic?

Nov 12: EXCLUSIVE: Fort Hood Suspect contacted Muslim Extremists

Nov. 14 Obama wants to delay Fort Hood probe

II.

Two observations. First, each title has an "angle." At the same moment the NYT and others were pushing the doctor/deployment angle-- and deliberately avoiding the Muslim angle, Fox and the Washington Times were featuring "Allahu Akbar" and minimizing any other factors. You will observe that reading only one "side" or the other would be worse than not reading any articles at all: you would have accepted a prejudice as "news" level truth. No outlet has a claim to the truth.

The second is about the phrasing. On Nov 7, the NYT reported, George W. Bush Visits Fort Hood, Wounded Soldiers, but Fox News adds "Secretly." Both articles are less than 5 sentences long, yet Fox uses "secretly" twice (in addition to the title) to convey the sense of a MacArthur coming to save the war. The NYT never uses "secretly," nor does it explain that the Bushes specifically didn't want any media to know they were there-- a fact which itself could be newsworthy. All four Fox sentences are about Bush; only two of the five NYT are.

Similarly, the "Obama wants to delay Fort Hood Probe" most certainly conveys a "do you see what this politically correct idiot is up to now?" Meanwhile, as the article explains, Obama really only wants to delay the Congressional probe until the FBI finishes its criminal investigation, which is not even a story worth reporting; Fox reports it only so they can attach that misleading title. They're banking on you doing what you probably just did, which is read only the title. You are left either with consonance with Fox ("Obama is an idiot") or dissonance ("I know Fox is an idiot, but I'm struggling with coming up with reasons why Obama might delay a probe. He must have a good reason, right?") Either way, they have caused you to think a certain way.

III.

What's very interesting-- read: depressing-- is how the news outlets protect themselves from the facts. For example, it's probably no surprise that the major focus of the Fox News articles on Nov 5 concerned Hasan's relationship to Islam. In contrast, on Nov 5, the two NYT articles do not once reference Islam. Indeed, one article almost goes out of its way to avoid it, quoting from some file: "no religious preference."   It then postulates "much about his background-- and his motives-- are unknown".

Yet the same NYT article that never mentions Islam does, incongruously, include a denouncement from the Muslim Public Affairs Council. It floats there, with no context within the article. This inclusion makes sense only if you already come in to the article with some knowledge that Hasan was Muslim. In this way, the NYT doesn't have to take any responsibility in spreading the "gossip" of an Islam link, but can simultaneously take credit for showing both sides (or the other side) of an issue.

In another, 770 word article of that same day, the word Muslim does appear-- only once: "a U.S. born Muslim." It's a fact no one would question. But rather than simply reporting this fact, they attribute the information as coming from... Fox News. Think about this: is the NYT turning to Fox News for information?   Of course not; they're distancing themselves from the information.

IV.

From here:

Viewership for the cable news channels surged on Thursday afternoon as news [of the shootings] shocked the country.

What station had the most viewers? Average viewers from 3p-12a:

Fox: 3.04M (usual 2M)
CNN 1.58M (usual 0.9M)
MSNBC 0.88M (usual 0.8M)

"The O'Reilly Factor" had 5M.

Discuss.

---

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===== ====== ===== The Last Psychiatrist: The Fraud Isn't Baby Einstein

it will teach skills he'll apply for decades to come

Nothing more powerful, not lava or sunspots or the hem of a woman's skirt, than self-righteous anger backed by the possibility you weren't wrong.

Parent alert: the Walt Disney Company is now offering refunds for all those "Baby Einstein" videos that did not make children into geniuses....the unusual refunds appear to be a tacit admission that they did not increase infant intellect.

The key issue is their marketing as "educational," a term which Disney dropped in 2006 after complaints by the FTC.

"The Walt Disney Company's entire Baby Einstein marketing regime is based on express and implied claims that their videos are educational and beneficial for early childhood development," a letter from the lawyers said,
What makes that claim false?

calling those claims "false because research shows that television viewing is potentially harmful for very young children."
Hold on: are you telling me that the Federal Trade Commission ordered refunds based on that??

Consider how hard it was for tobacco makers to be forced to do anything despite the science being everywhere. There isn't anything conclusive about TV watching. I'm not saying TV is good, I'm saying wow, they can wreck a company over "some research suggests?"

The FTC response was slightly different:

Upon careful review of the matter, including non-public information submitted to the staff, we have determined not to recommend enforcement action at this time.

We note that certain claims-- such as that a product "introduces" or "resents" or "exposes" children to certain content-- are unlikely, by themselves, to convey an educational benefit...
And as for TV:

To the extent the existing research does point in any direction, it suggests that television is an inferior means to teaching very young children compared to live demonstration...additional research is needed...

In other words, Disney gave the refund because not because the FTC made them, but because there was a shakedown, in the form of a potential class action lawsuit, in progress. That's America.

II.

In every article, there is a jab at the parents who bought them. "Did you really think it was going to make them smarter? Idiots!"

It seeems that what was under attack wasn't Baby Einstein, but the type of parent who would buy Baby Einstein-- middle to upper middle class new parents, unsure of their skills, looking to give their kid any possible advantage since they're not sure exactly what to do to raise a kid. Pre-school ballet, soccer, violin, Mandarin, Gymboree-- throw everything at him. "Don't these idiots know none of that works? That's why I didn't do it."

USA Today:

The popularity of Baby Einstein also reflects a misunderstanding about the true nature of genius. Just a little life experience, even a few days in a regular U.S. school, demonstrates that geniuses are usually born with innate gifts that no DVD can impart.

In other words: duh, and phew.

But no one was shooting for genius-- they were shooting for smarter, or at least not as damaging as TV. And if you think that "smart" isn't affected by even haphazard early interventions, then you're insane. How's that for semantic blurring?

III.

There's plenty of criticisms to level against overinvolved parents, but they are trivial in comparison to the main one: they check out when the kid is in 1st grade. Once the kid hits grade school, the whole ship is put on autopilot, and the two biggest forces in a kid's life from 6 to 18 are school and "the media"-- TV, internet, video games. I dare you: go and log, on paper, a kid's typical day.

This applies equally to lower income kids, for whom school often represents their only chance; to rich kids in private schools, whose parents figure if it costs $20k a year...

Trusting a ridiculous public school system to prepare for an even more ridiculous college Ponzi scheme. "I got a B.S.!" Aces.

Early interventions-- both in education and in psychiatry are important in their own way. But the focus on early intervention is a way of avoiding the hard work: turning teens into adults. That's where the money is. I mean isn't.

---

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===== ====== ===== The Last Psychiatrist: The French Obey Authority Figures

do the right thing

I.

A French documentarian creates a fake game show (a la Milgram obedience experiment): he tells the subjects that in this game show, they are to shock the "contestant" if he answers the questions wrong. (Of course, there was no real shock, everything was faked.)

Just like with the Milgram experiments, most (64/80) of the subjects shocked all the way to the top, despite the anguished screams of the contestant.

Milgram would (and did) say something like:

But the psychological conclusion, at once both facile and unimaginable, is that they were simply following orders: they hated making Jean-Paul suffer and expressed their desire to stop the game -- but, apart from 16 of the participants, never managed to resist orders from an authority figure to carry on.

II.

Here are two important questions I have yet to see asked:

are there really people in France-- in France!-- who have not heard about the Milgram experiments?
are there really people in France who would think that there could be a TV show where you actually torture other people for real? I realize the EU is crumbling, but let's postulate that France is not in Japan.
It's possible that these people are not so much obedient as idiots, condemned to repeat history because...

III.

But there's another, more likely explanation: these people live in France.

They're brought up in a normal, liberal society that doesn't usually torture its citizens. It's a TV show, so it's presumably voluntary. Why would they stop? Imagine you're the contestant to receive the shocks, you've withstood shocks all the way up to 400 volts, and now the nimrod on the other end decides he's not going to shock you because he finds it morally objectionable-- the same guy who's never heard of the Milgram experiments yet has made a thorough investigation of the relevant balance of ethics. Now the game is ruined, and you go home with your depression treated, for nothing.

There's a difference between blind obedience to an authority figure, and knowing where you are.

IV.

A lot is made of whether the individual has the moral fortitude to resist an authority figure. What of it?   No one cares about your particular moral stance, except you, which puts that squarely in the narcissism bin. You can refuse to participate, but you know they'll simply get someone else, right? So what have you accomplished?

The important question isn't whether you would refuse to participate, but whether you'd be willing to smash a fluorescent light bulb and wave it around like a light saber and bust that guy the hell out of there. Or something. No one expects you to be a Jedi, but don't walk out of there with your head held Facebook high because you chose to think of yourself first.

---

Zimbardo and the Stanford Prison Experiment

Why I Refused To Participate In Milgram's Experiment: I'm a Communist

----

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===== ====== ===== The Last Psychiatrist: The Girls Of Pfizer

http://www.youtube.com/watch?v=F_tkar2rLEQ
Oh, get over yourselves. That's hilarious.

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===== ====== ===== The Last Psychiatrist: The Graying Of Kindergarten: The Goal Is To Keep Them In Puberty, Part 1
The article is actually called The Lengthening of Childhood, but somewhere sometime the other phrase caught on, which is a shame, because this phrase is much more accurate.

The facts are these: a trend that began in the 1960s is holding back kids one year before they start kindergarten. Instead of starting at 5, they start at 6. Part of this is due to changes in state laws which have pushed back the enrollment age cut off (e.g. must be 5 by September, instead of by December). But this is only a small part.

There are three important trends.

First, the kids held back are not being kept at home-- they are being enrolled in preschools. So it is a purposeful delay of kindergarten specifically, not a delay of "going away to school."

Second, upper income, white parents hold their kids back at the highest rate. Infer as you will.

Third, boys are held back at higher rates than girls, and this difference is increasing every year.

Unfortunately, the authors draw the wrong set of conclusions from these findings. For their own (good) reasons, they are arguing the impact on society, not on the individual.

For example, while there is a clear benefit in the first few grades to being one year older, the authors find that this improvement is not present later on in high school. In fact, they show, the older kids are at a significant disadvantage-- for example, higher drop out rates.

But if a kid is one year older when he drops out, he'll have finished one less year of school, so yes, he'll be less educated. But the expectation of the kids of the upper income parents-- the highest rate-- isn't that they're going to drop out. So this negative doesn't apply to those kids.

Similarly, the authors say the delay depresses lifetime earnings; but this is obviously only because they will work one year less in their lives. Again, the individuals themselves don't care about this; society and the tax collectors do.

Where they do see benefit is in athletics: an older varsity player will be, on average, stronger than a younger one. The practice of benching someone for a year so that they get older is redshirting, and the authors apply it to the kindergarten process as well.

So on the one hand, the practice has two clear negatives on society; but the more urgent question-- the one that would actually influence the practice-- is the impact on the kids themselves..

First, you have a class problem. On the one hand, it sounds easy to criticize this practice as the social engineering of the rich. But, on the other hand, if the other parents around you are doing it, how can you not do it yourself? Would you willingly put your kid at a theoretical disadvantage when you have the means to not do that? It's similar to the universal healthcare counter-argument: can you force a group of people to accept worse healthcare than they are getting now? To accept it for their kids?

And this puts pressure on less affluent but aspiring parents to do the same-- the difference being that their five year olds won't be in private preschools, they'll be in daycares. They will, in effect, get one less year of "education" than the rich kids. What they hope will be a competitive advantage may be a disadvantage. In other words, they' might be screwed either way.

As I say to everyone who will listen, which is no one, you can't blame the rich for doing it, and you can't blame the poor for wanting to riot.

Second, one might ask why this is happening to boys more than girls. It's obvious to anyone who has ever seen a boy that they appear, as compared to a similarly aged girl, completely retarded. So it makes sense that affluent parents-- any parents-- who have the option, will redshirt their five year old boy and hope he gets another year of maturity under his belt so that-- and this is my point-- he can keep up with the girls. So the problem isn't simply that boys mature slower than girls, it is that they are required to perform the same exact skills at the same exact time. Any surprise boys hate school more, "ADHD" is more prevalent, etc? And there is more anxiety and thus pressure about the potential ineptitude of sons than daughters.

What's interesting and upsetting about the discussion of redshirting is that it is phrased in terms of class differences, which are the consequence; and not gender differences, which are a source. The problem isn't redshirting, the problem is the school. You expect your five year old boy to read like a girl? And when he doesn't-- what? Hates reading? Hates girls?

Third, you have the problem of the parents themselves who are looking for every advantage to give their kids because they don't know what else to do, they can't judge what's valuable or not. So they look around at other kids and parents, and compete. They don't know what the point of an education is, so they say "get into a good college." That's the goal of 18+ years of education. That single outcome.

For what? They pretend that they have to do these things because the other kids do have these advantages, but they have no faith in the kids themselves-- that their outcome will be largely independent of what college they go to or even if they go to college. College is, in a word, a scam; everything that promotes that goal is therefore doubly so.

I'm a doctor-- no one has ever asked where I went to college; no one has ever asked how I did in high school chemistry.   You can argue these things were important then, to get into medical school, but they really weren't. Getting Bs instead of As may have meant I went to a different school, but not that I wouldn't have been a doctor, or a good one, or a bad one. And since my real education didn't come from the schools anyway, it's moot.

I wonder, and I have not studied this, if one positive consequence of redshirting is that studies that show American students are dumber in math than other international kids may be bunk, since those studies compare kids of similar ages, not similar grades. Our 15 year olds may simply be in an earlier grade. This may also explain why the education gap disappears in college.

I'm tempted to conclue that the problem of redshirting is analogous to abortion: instead of trying to convince people it is a good or bad thing, we should just try to eliminate the need for it.

----

Part 1 here. (This is it.)
Part 2 here.
Part 3 here.

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===== ====== ===== The Last Psychiatrist: The Harvard Cheating Scandal Is Stupid

discussing it with people in government is fine because it won't help. good luck

CAMBRIDGE, Mass. -- Harvard University is investigating what it calls an "unprecedented" case of cheating. College officials say around 125 students may have shared answers and plagiarized on a [Introduction To Congress] final exam.

What a scandal that such a thing would happen at Harvard! "Academic integrity issues are a bedrock of the educational mission." And etc.

Before everyone rushes to their predetermined sides, can we ask why, when there are cheating scandals, they are almost always in introductory classes? When the stakes are lowest?

75% of the students in these kind of courses get As and Bs because of Grade Inflation. I'd put big money down that if I used a crayon to draw an elephant and a donkey I'd get at least a B+ with the margin comment, "Interesting take, could you elaborate?"

And yet the students here felt compelled to cheat. Take a minute away from your self-righteousness and put yourself in their shoes. Did they not think they could get an A on their own? Or.... is "cheating" the only way to create the kind of answer that the professor wants?

Let's find out. Here's the test:

"Using in-text citations to support your answer" is the standard way academics pretend at knowledge, and it is always a trick, it doesn't allow the reader "a better understanding of your thought process," it is an appeal to authority (Salmon 2006) masquerading as critical thinking (Ennis 1987). But it sure makes grading easier, here is the answer key: >5 references: A. 3-4 references: B Etc.

If I gave this test to other government professors not affiliated with the course, I'm sure they'd have good answers-- but would it be "what the professor is looking for?" That's the phrase that alerts you to the fact that the class isn't designed for you to learn but for him to teach. All for the fair market price of $2000.

II.

You know what's funny? If 125 American soldiers all simultaneously broke some military rule of conduct, the noise that would blow out your eardrums would be Harvard professors yelling about how the administration was to blame for creating a culture that facilitated that misconduct. "This is not the random acts of a few bad apples, this is a natural consequence of the policies of Rumsfeld and Cheney!" Short memories, everyone? Not me, I drink to remember, and I drink a lot.

There's your hypocrisy, and it is magnificent in its conscious blindness and unconscious rationalization. I defy you to find me one single professor that is now asking, "seriously, gang, what the hell kind of operation are we running here where 125 of theoretically the brightest kids in the country-- who can all pass physics and organic chemistry and write novels and play music without ever cheating-- then do it in a $2000 Intro To Gov class we probably shouldn't even be offering?" Any soul searching?   Deconstruction of the system? Sleepless night over destroying the lives of 125 kids? Anything?

Harvard says that it noticed students used similar phrasing and strings of words, which could signal cheating but let me offer a more uncomfortable alternative: the gated community of academic jargon.

On a hunch, by which I mean a complete and utter certainty, I hit up some of the course professor's academic papers. Here is the very first sentence in the very first paper I read:

Context is the frontier of participation research.

Right. 7 simple words, have any idea what the hell they mean? Don't think too hard about it: they don't mean anything. Professor Platt is eyeballs deep in academiaitis, the jargonization of the meaninglessness of the work. The move is to make you feel stupid so you don't see this meaninglessness, for example when you're confronted with a paper titled in the following format: X, Y, And Z: 15 To 20 Syllables About Something No One Gives A Damn About, where X and Y are linked rhythmically if not semantically and Z is an abrupt non-sequitor indicative of the writer's atrophied left cerebral hemisphere (Gray 1918). For example:

Boons, Banes, and Neutrals: Contest and Disparities in Political Participation

and

Innovation, Inevitability, and Credibility: Tracking The Origins of Black Civil Rights Issues

Those are both his, I knew they would be there before I looked for them, and I knew this because 125 people simultaneously understood that there was no way out except to "cheat" on a final they were all going to get As on anyway. I don't blame him for writing like this, for thinking like this: that's how he was taught to think and write (which is why his final exam questions are incomprehensible), and he would never have gotten his PhD unless he wrote like this, because either you are part of the system, or you are an enemy of the system. There are no other choices, and he chose a. Please note a= Assistant Professor.

So the point here isn't a critique of Professor Platt's academic career, but that he is now paid to teach his sleight of hand illusions to students who find themselves... at a bit of a disadvantage. "This is how intelligent people think," they're told. Granted, it does seem complicated. But the whole thing is a carnival trick, because what the students do not know, what they have not been told, is that it is completely impossible to summarize jargon without appealing to that very jargon; that the moment you try to explain, in simple ordinary English the meaning of the jargon, your whole paper ends up being three sentences. So what can you do when the question asks for 2-4 pages, other than copy "similar strings of words?" You could run a po-mo generator, I guess.

Because I know that some of you over 40 are stupid, I will state explicitly that of course cheating is wrong and it shows a lack of moral character, but I am forcing you to ask whether 125 people simultaneously cheating might be indicative not of a sudden resurgence of Satanism but an outbreak of encephalitis, with Professor Platt as Patient Zero?

This is why I am able to say, controversially but with absolute certainty, that everyone in that class cheated: if they didn't copy off of each other, they copied off of the professor, with no internalization of the "knowledge" because that was never the point of the class. If you want to try and tell me how those are any different, I'll be at the bar.

So let me make my own counter-allegation: the students aren't guilty of cheating, the university is guilty of entrapment. Here's what you're not allowed to do: ask a basic question, "Do interest groups make Congress more or less representative as an institution?" and then threaten that "the response will be judged on how well it draws from the course materials to make an argument." NO. You could evaluate the answer on its merits or the rigor of the thinking, but whether and how it draws on the course materials is exactly what you do not want-- it facilitates the grading of the essays, sure, keeps everything inside the gates, but it derails learning. When you write that, you force 125 people to collaborate on the real final exam question: "What does the professor want?" Apparently, what he wants is an easy way to grade, and you all got caught accommodating him.

Since this is a government course, let me give you an important lesson in government, one which, unsurprisingly, is never taught: "It is not the young people that degenerate. They are not spoiled until those of mature age are already sunk into corruption." That's Montesquieu. Don't worry, it won't be on the test.

http://twitter.com/thelastpsych

--

Are Law Schools Lying To Their Applicants?

===== ====== ===== The Last Psychiatrist: The Hidden Zero Effect

Choose:

$5 today or $10 in a year.

Picking $5 is called temporal discounting-- you pick a sooner-but-smaller outcome simply because it is sooner.

But it's more than a preference based on how soon you get paid. If the question is changed:

$5 in 7 years, or $10 in 8 years

Then you can feel the pull to choose the $10-- even though the $5 is still one year earlier than the $10. So it's not simply people prefer sooner over later. It's also how far away the payoffs are. How soon is sooner? At some point in the future, your choices flip.

In fact, this is predictable (reliably so in animals)-- and follows a hyperbolic function:

Imagine there is a smaller-sooner reward at time T3, and a larger- later one at a time T4. At a very distant, early time T1, you prefer the solid line (the larger-later reward), because they are both far enough away that the time delay seems insignificant.

But if you choose at a close time T2, the choice has flipped and you prefer the smaller reward, because it seems sooner. The closer "soon" is, the more you're willing to settle. Hyperbolically.

II.

Why does this happen?

It's behaviorism. The effect of rewards are temporally dependent. Try it on your kid.

How this phenomenon is described is important, and it is frequently backwards. You don't prefer sooner choices that are smaller, but if they are both far enough away you'll choose the larger choice; you choose the larger choice all the time except if the choice is asked of you close to payoff.

If you intuitively know your future is long, and real, you don't succumb to it as much. But if the future is an abstraction, then you begin to discount your choices.

The future is real only if you are real, i.e. your identity is fixed. If your identity is in flux-- whether from personality disorder, bipolar, being a teenager, going through a divorce-- if there are different "yous" all the time, you cannot make decisions based on the future. If "you" aren't going to be the same in the future, how can you make decisions about it?

In other words, temporal discounting is not exactly an error; it is an accurate reading of the likelihood of change of one's identity.

III.

So how do you resist this?

One way is to make explicit the hidden zero:

Choose $5 today and $0 in a year, or $10 in a year and $0 today.

That hidden zero seems obvious, and it is obvious cognitively, but not instinctively. These habits and "errors" are hard wired in us because they are protective-- eat while you can, jackals are coming.

But they don't help when you're opting into a 401(k): "Choose $13,000 today and $0 at retirement, or $0 today and $13,000 at retirement."

When you make the hidden zero explicit, people choose differently-- less impulsively:

Whether it's real or hypothetical money, people choose sooner-but-smaller less often when they are told about the $0.

When dealing with impulsive people, or people whose identity is in flux, it is important to make explicit all parts of a choice, because time has little meaning.

IV.

But what caught my attention about this is the difference between real and hypothetical money. Why does making it real money significantly reduce the number of sooner-but-smaller choices, whether or not the zero is explicit? If anything, seeing the money on the table might drive them to choose the sooner (but smaller) choice-- the instinct becomes real ("eat now.")

The experiment was to ask subjects 15 questions of the form "$X today, or $Y in a month." But a second group of people, the "Real Money" group, were told that one of these hypothetical choices would randomly be used to pay them real money at the end of the questionnaire.

Do you see the problem? The subject isn't making a choice between a sooner payoff vs. a later payoff, but between sooner payoffs vs. all the other sooner payoffs, and later payoffs vs. all the other later payoffs.

Immediate rewards ranged from $2 to $8, delayed rewards ranged from $5.40 to $8.70, and delays ranged from 7 to 140 days.
In effect, this stops becoming a temporal discounting problem and becomes a game theory problem. He's maximizing the sooner payoffs, the later payoffs, and then also temporally discounting. E.g.,

$6 now, or $12 in a month----- he chooses $6.
$8 now vs. $10 in four days---- he chooses $10.

But now he's told one of these choices, randomly, will be paid to him. So instead he picks:

$6 now vs. $12 in a month--- he chooses $12
$8 now vs. $10 in four days-- he chooses $10

Because in the first pair, he would have been paid either $6 now or $10 in four days. "No way, I'm not risking losing $10 in four days just to get $6 now. In order to risk losing $10 in four days, I need a bigger payment down the road. The only choice available to me is $12, so I'll take it." Get it?

Aggregate 15 such choices and it's no surprise people pick larger-later payoffs more often. The real way to do this would be to offer the people real money for every single choice they made, but that didn't happen here.

Unfortunately, it doesn't happen in real life, either. Most of the time, people make decisions based on hypothetical scenarios, with a faint expectation that perhaps one of these decisions will result in an actual payoff.   When people with identity issues are presented with a series of binary choices, we expect them to consider them independently, and we often marvel at how bad their choices seem to be. But they may be taking a series of binary choices and inappropriately pooling them to maximize an overall outcome.

That's why we get frustrated with their choices. We can't understand why they made that choice because the reason has to do with an entirely different decision that should be unrelated but to them is linked.

And so it becomes important to restate things into independent, binary choices. Certainly life choices are affected by other life choices, but for those floundering in their own identities, things need to become more concrete, not less.

===== ====== ===== The Last Psychiatrist: The Hunger Games Is A Sexist Fairy Tale. Sorry.

this isn't going to have a happy ending

You should probably read this first.

I.

Housekeeping: it's legitimate to accuse me of being drunk or a terrible writer, both are true. But you can't say I didn't read the book and didn't see the movie. I know I did, I was there.

When I say Katniss was continuously robbed of agency, that's a simple fact. Let's examine the commonly cited counterexample that she killed two people by dropping a hornet's nest on them. Didn't that require her to plan and act, to know the consequences? Isn't that agency?

Chekov famously said "If in the first act you have hung a pistol on the wall, then in the following one it should be fired. Otherwise don't put it there" but the flip of that is that if you don't put a pistol on the wall in the first act, you can't suddenly have the main character find a pistol on the wall. Unless you're writing a fairy tale.

So when Katniss is desperate, trapped in a tree, and has no recourse-- and suddenly someone points out that there is this immensely lethal object right next to her, maybe it's a hornet's nest and maybe it's a thermal detonator-- so the story then has to take a three minute pause so an omniscient narrator can explain to the audience what it is because we had no knowledge of this before, "oh, it's magic bees," then there are only two possibilities: 1. Deus ex machina. 2. It's a terribly written story. I favor 1, but I'm open to 2. Oh, and it kills everyone but Peeta, that's lucky.

II.

The standard adulation for The Hunger Games is that it has a strong female protagonist who is, and I quote, "a badass." Is she more of a badass than Alice from Resident Evil?   Come the zombie apocalypse, do you go Team Katniss or Team Alice? Not who it's cooler to say you'd pick; assume you have a 5 year old daughter with one hit point left whose life depends on your selection. Because I'm arguing that it does.

actual badass

Obviously ===== ====== ===== The Last Psychiatrist: The Legend Of Steven Colbert

if he's the last man on earth, to whom is he a legend?

a.

The global capitalist system is approaching an apocalyptic zero point... comprised by an ecological crisis, the consequences of a biogenetic revolution, imbalances within the system itself, and the explosive growth of social divisions and exclusions.
So goes the premise of Slavoj Zizek's new book, Living In End Times. It's analyses are seductive, and from what you'll hear other people tell you about the book that no one will read, you will conclude, "this is a guy who gets it!" Well, he doesn't.
This is a very good rule of thumb: anyone who tells you we are living in end times is wrong about pretty much everything.

I. To Whom Am I A Legend?
I Am Legend is the third substantial retelling of the novel by the same name (1954), the other two movies being The Last Man On Earth (1964) and The Omega Man (1971).
All four stories follow similar plots. A plague has killed off humanity, except for some who have been turned into zombies/vampires. One human, Neville, survives.
A series of remakes can often be a window into the evolution of a culture, and so it's useful to look at what's the same and what's different over time.
In the book (1954), Neville fights against vampires, but also a group of infected but still human creatures. They finally capture and execute him, not least because he is different, the last of a dead race. These infected humans have a functioning society of their own; as the majority survivors, the world belongs to them. Neville sees that they look at him with fear and disgust, the way he looks at them. As he is executed he realizes that they will remember him as a legend(ary monster.)
This is a truly multicultural theme, Neville's human tradition parallel but not superior to the infected's. (History is written by the victors.)
The first movie slightly but importantly changes the ending. Instead of being executed, he escapes to a church, but he is finally speared on the altar. Defiant to the end, Neville says he is the last true human, and the rest merely freaks.
By The Omega Man, the multicultural theme is avoided. Here, the survivors are a mutant species of humans. Crazy as they are, they voluntarily choose to live away from technology and modernism because that's what got them into this mess in the first place. Neville, however, has found a cure, so even if Neville represents something terrible and fearful to the mutants, he is still the normal while the mutants are pathology.

In I Am Legend (2007), the multicultural reversal is completely extinguished. Will Smith (thinks he) is the last human, and at war with the vampires. He later discovers a woman and a boy trying to meet up with other survivors living in Vermont in a walled compound. In the final scenes Neville "adopts her fundamentalist perspective and adopts a Christological identification": he stays behind to fight the vampires (and dies) allowing the human survivors to escape with the cure. So Neville becomes a "legend for the new humanity whose rebirth was made possible by his invention and sacrifice."

II. Multiculturalism On The March/Decline
So goes the reading of the movies by Zizek. It is the evolution of multiculturalism played out in cinema. So far, so good.
But Zizek has a point to make, and that point is that Hollywood got it backwards. Why would Hollywood insist on making less multicultural movies, while real society becomes more so? In 1954 multiculturalism was nonexistent; in 2007 it's practically an official ideology. If there was a society that was "ready" for a movie that puts all traditions on an equal level it would be eyeballs-deep Multicultural America, where every reference to another society is qualified by, "but we have to respect their traditions/what makes our ways better than theirs?"

The answer is that we have regressed; what should be the correct, multicultural, understanding of reality (all traditions are equal in value) was ducked, and a lie reinstated (we're better) in order to preserve the existing (though dying) social order. More plainly: conservatives have taken over Hollywood. These are all tricks to protect global capitalism.

III. Write This, Not That

If you're having trouble with that line of thinking, you'll have trouble with his whole philosophy, aptly summarized on page 3 of the Introduction:

In today's post-political democracy, the traditional bipolarity between a Social-Democratic Center-Left and a Conservative Center-Right is gradually being replaced by a new bipolarity between politics and post-politics: the technocratic-liberal multiculturalist-tolerant party of post-political administration and its Rightist-populist counterpart of passionate political struggle-- no wonder the old Centrist opponents (Conservatives or Christian Democrats and Social Democrats or Liberals) are often compelled to join forces against the common enemy.

I'm not going to make the dozen easy jokes, I'll say simply this: when writing becomes so complicated that only the initiated can understand it, then it is meant only for them. Who is he going to convince by hyphenating every third word set? Nobody. It's masturbation, though considerably more difficult.

IV. Will Smith Is Black???

I Am Legend probably never had so much analysis, but let me throw in something Zizek missed: Neville is black. There's your multiculturalism, at least all human races are equal in their superiority to vampires.

They could have easily made the vampires a functioning society instead of animalistic marauders, thus allowing for a deeper multicultural comparison. For example, why not a 9/11 allegory?   Black and white rural Americans united against New York Muslims? A few days after 9/11, MTV interviewed the Wu-Tang Clan's Method Man about what should be done to prevent another attack. His response was (paraphrasing), we're going to have to start searching Muslims, stop them in their cars and at airports, etc. That the usual prime target of every possible kind of profiling was now suggesting that the solution was more racial profiling was an irony totally lost on him. But nevertheless a film that shifted the players in the multicultural hierarchy but kept the theme intact should have been welcome in 2007. It wasn't.

The question is why it wasn't. There are huge ethnic divides in the world, not to mention poverty; "invisible people" marginalized, contained, unrecognized. So why does Hollywood insist on making movies that inferiorize the other?
Zizek's answer is, "collective fetishistic disavowal," which is denial. We know the global capitalist system is in crisis, but we're going to carry on like it's not. Hollywood facilitates this. Important point: Hollywood facilitates this, not reflects this, because Hollywood is an extension of global capitalism.

V. Do You Swear To Tell The Truthiness?

Steven Colbert appeared before the House immigration subcommittee as an
"expert witness"
on migrant workers.   Pause for effect.
Steven Colbert is a person, but you have undoubtedly only seen the character Steven Colbert. What's he like in real life? Who cares. That's not what you pay him for.
This wasn't the typical Hollywood Star Testifying Before Congress routine, and at least those actors have the decency to signify that they are experts by wearing glasses they don't need. No, he stayed in character the whole time, so his appearance before the Committee was jarring, seemingly uncanny. What next, Robocop? Was it appropriate to play a fictional character before Congress?
And many congressmen/people said no, which on first consideration seems correct. But.
But if you're focusing on a man playing a character for the benefit of TV cameras, you are looking in the wrong place.

Those hearings themselves are staged. They are purely for display, as a means of getting things into the public record. This isn't a metaphor, this is the literal truth; there is no institutional expectation that real work is conducted there or that they even reflect the actual beliefs of the individuals speaking. They're reading their lines.   "What's my motivation? Oh yeah, Monsanto." Real business is conducted in the back.
Steven Colbert is a character that the public has voted on to several seasons of TV. He's sticking with what works. Congressmen are no more "real" than he; molded to represent the will of their perceived constituents. Or did John McCain really think of himself as a maverick? George Bush and Dick Cheney were anti-gay? Those are characters.
No to mention that Colbert's character is decidedly more consistent. How many people pictured above have to please their voters even as they must serve their donators?
Steve Colbert didn't crash the party, he was invited. No one refused to appear with him. No one criticized the fact of his appearance, only what he said or the way he said it. "I think his testimony was not appropriate," House Majority Leader Steny Hoyer (D-Md.) said. "What he had to say was not the way it should have been said."
The most you can argue is that Colbert wasn't an expert in the testimony he was giving, but, as he pointed out,

"Does one day working in the field make you an expert witness, do you think?" Rep. Lamar Smith (R- Texas) asked scornfully.

"I believe one day of me studying anything makes me an expert on something," Colbert replied confidently.

"Is that to say it's more work than you've ever done before, right?" Smith followed.

"It's certainly harder work than this," the comedian deadpanned.

He's not an expert, but he had, at that moment, more experience with the question than most everyone else in the room. (This is the person who engages in argument to undermine the system (treats the problem as symptom rather than fetish), but who also distances himself from his position through the process of critical analysis (i.e. he knows what he is doing)).
And the very difficult thing to accept is that he also has more power. I realize that TV guys don't vote on immigration policy, but I can absolutely swear to you unconditionally without any qualification, that immigration policy will go the way TV wants it to. They control the horizontal.

VI. The False Choice

Here's a typical Zizek line of thinking. Say you want homosexuality to be accepted. So The Powers That Be tell you, "on penalty of death, do not dare make insulting comments about gays." Got it.
Or, TPTB can go postmodern on you, and instead say, "look, you have freedom of speech to say anything you want, but it's ignorant to make insulting comments about gays." That's the approach in place now, and it's much more powerful. It offers you a false choice, but you understand that you have to keep your remarks to yourself, or else something will happen.
This description makes perfect sense. Americans of every political persuasion feel this false choice. They're told they have these freedoms that, in fact, they really don't.   And the false choices are everywhere: watch whatever news you want, but everyone knows these are the only legitimate choices. No one can dare tell you what kind of diet you have to have, but your choice is high fructose corn syrup or aspartame. Eat it.
From this very clear description of the problem comes the most terrible solution imaginable: let's go back to the authoritarian approach. It's more honest, and in this way we can effectively build a better society. You proletariat are either going to be controlled directly, or indirectly, but controlled you will be. At least if you can get the right people controlling you, they'd at least force you to eat something better than high fructose corn syrup. That's what he thinks would happen.

Well, they already tried this in a movie, and it was called Soylent Green.

VII. I Am Legend In The Only Place That Counts

You'll observe that the title of the movie is I Am Legend, not We Human Beings Are Legends. I. The point that has escaped Zizek's notice is that the I in I Am Legend doesn't depend on the presence of other people. Note that Neville makes jokes and stays "in character" even though he's talking to mannequins or a dog or no one. He can't help it: he's a human, and he was born after 1960. Zizek is worried about some fantastical move by the culturally powerful to elevate themselves and others to a superior state, but that would be a dramatic misunderstanding of the situation. The correct interpretation-- i.e. the only one that is correct-- is that from 1954 to now we have moved from human cultures in conflict with weird, strange, other cultures (e.g. the Italians), to a near total awareness of all existing cultures that we find annoying. The result? We hate everyone equally.   We are perfectly aware that to the vampires and Muslims we are evil, scary creatures, but that doesn't make them less scary or dangerous.

Hollywood got the evolution of the culture right, not wrong. The next remake will be titled, I Am A Main Character In My Own Movie, everyone else be damned.

VIII. Who Would Win In A Fight?

Back to Zizek and his key error. If you take him at his word, there are "inherent contradictions" in the very structure of capitalism that make it untenable; no one needs to destroy it, it will implode on itself. Similarly, the media moguls don't have to be in cahoots with capitalists because the media itself (that structure) is part of capitalism (it creates wants, branding, etc.)

The media creating wants and branding has nothing to do with capitalism, it has everything to do with human psychology. Even in a perfect (communist) utopia you could not kill off capitalism because capitalism is the sublimation, the "correcting" of the natural human impulse of envy. It either bubbles up and corrupts you, or you create a natural outlet for it. There aren't alternatives. If global capitalism implodes from the weight of its inherent contradictions, it will simply be replaced by... global capitalism. Because it's run by humans.
But none of that matters, because even Zizek doesn't believe his own theory. He can write 600 pages but in the end what he blames are individuals.
Zizek, like all important bearded lefty communist who can outthink you Central Time NFL lunatics, derives his entire philosophical system from one single axiom: the powerful control the powerless. It may be phrased in terms of competing narratives or systemic contradictions, but it's all George Bush's fault nonetheless, and it is also Kim Jong Il's and Putin's and Maos's in as much as they (as individuals) are part of the capitalist system. His solution is "a return to a Marxian critique of political economy." When you hear someone in the front seat say that, hold your breath, you're driving by a graveyard.
There is no concerted effort to promote global capitalism, not in theory and not in practice. There's no concerted effort to do anything, which is itself a problem but at least puts the Marxist angle to rest. These things you see happening aren't capitalism's fault, they are people's fault. There are corporations and individuals with their own personal interests that sometimes align and sometimes don't. I'm sure the CEO of Exxon and the CEO of Apple often apply their considerable power towards similar goals, but the moment Steve Jobs discovers cold fusion we'll all be lamenting how pancreatic cancer takes the best of us.
"They pressure the government to keep their corporate taxes low at the expense of healthcare!" Wrong. Each corporation pressures the government to keep their own corporate taxes low, period. That they're all temporarily united on this is convenience, if Apple's taxes have to go up in order for Exxon's to stay low, we're all going to have Droids. "But they all serve on each others corporate boards!" That's not collusion, that's keeping your enemies closer.
I can say all this with confidence because, as far as I know, corporations and governments are made of human beings, and human beings are envious, petty, anxious, and above all mortal. What sets us apart from each other is how we manage those inherent flaws. All of their power is the power of individuals. When you say "Exxon tricks us by offering us a false choice of oil vs. unicycle!" you really mean that this guy is tricking you:

Really? Look closely. Really?
That's the problem with his "false choice" model above: there aren't any Powers That Be trying to trick you. Maybe in 1960 when we had superpower politics, and in 1939, but not now. There's no concerted effort to control society, so there is nothing to rebel against. The false choices work on you not because TPTB are devious but because you will murder your own family to avoid shame. All the control is self-imposed.
And don't let Zizek hoodwink you; he'll say that the power isn't in individuals but in the structure of capitalism itself-- the rules and the initial allocation of rights that results in the outcome you see--no one has to act deliberately.   That makes for good theory, but Zizek doesn't believe it himself: it is still the execution by individual actors (who are part of the system, I'll admit) that must actively work to keep capitalism propped up. Otherwise, according to him, it would be gone by now.
So to Colbert. It would be awesome if all of this was planned, if there were some secret cabal who brought Colbert in specifically to mask the contrived meaninglessness of the Congressional Hearings, i.e. to make them seem more real than his simulated reality, and no doubt Zizek would see something along those lines. And it would be comforting to know that the chaos around us was really under someone's watchful eye. But the truth is there is no such cabal. If you extraordinary renditioned Steven Colbert and waterboarded him to name names, he wouldn't know what the hell to say to you. As far as he's concerned, he duped them.None of this was planned, indeed, none of it has any point whatsoever. They invited Steven Colbert because... he's Steven Colbert. There is no meaning behind it at all.

IX. Will Smith Is Black?

Zizek holds up I Am Legend as an example of preserving the current state of global capitalism, but in fact that movie is the perfect example of Hollywood's disinterest in preserving anything except it's own immediate survival. They put Will Smith in the movie not because he is black and it offers a different version of multiculturalism, but for the simple reason that he is the most bankable actor in Hollywood. In other words, not because they like him but because we like him.

Furthermore, the ending of I Am Legend that you see today-- the non-multicultural, kill all the mofos one-- is the revised ending. The original ending was the multicultural one-- Neville realizes the vampires have their own society, returns the girl to them, and they part ways, parallel traditions, humans living one way and vampires living the other way.

This was the ending Hollywood wanted, but it was rejected by the (test) audiences. So Hollywood changed it, not to serve capitalism but to make a profit for themselves. It was that simple.

What you see isn't a systematic attempt to hide the truth from you, but the accidentally organized and random conflict of various individuals which has resulted in both iPads and temporary 10% unemployment. It is comforting to blame this on some flaw in the system, but there is no system, there is only people, and they have no time for theory. In theory, there is no "they"-- just psychology the result of language mediated by these capitalist interactions. Bu tin practice, there are lots of theys, and they act in completely unpredictable ways-- unpredictable if you're looking at them as cogs in a system. Over beers and hash we can debate whether global capitalism requires emergency shifts into socialism, or not, but don't think for a moment it is organized or hierarchical. And thank God.

Real control-- positive and negative-- comes from within. Those guys don't have to lie to you. You are being lied to, by yourself. If you want to change it, now you know where to start.

---
Addendum: too many emails about Bernie Madoff, so:

So, you know, there is a structural problem beneath all this psychological topic of the greedy bankers, which is, that's how capitalism works, my God, which is why even concerning our beloved model--Bernard Madoff, no?--I didn't like it how they focused on him. He was just the radical version of where the system is pushing you. Now, I'm not saying--I'm not crazy--"which is why we need to nationalize all banks and introduce immediately socialist dictatorship" or what. What I'm just saying is, let's not get rid of the problem by too easily making it into a psychological problem. You know, you can be an evil guy, but there must be very precise institutional, economic, and so on, coordinates, background, which allows you to do what you do.
That it's not a psychological problem is an odd thing for a psychoanalyst to say. But nevertheless, that Bernie Madoff knew how to work the system is different than saying the system allowed him to do it, or that the system creates Bernie Madoffs, or that he is simply an extreme case of what the system creates. The system doesn't do anything, you do it all in reaction to the system. Bernie Madoff did those things because of... Bernie Madoff. To the extent that the institution itself is to blame, he should get less time, otherwise it is merely revenge; which it is, because there's no system: it is punishment handed out by individuals against another individual, or, more accurately, individuals manipulating the system to get the outcome they want.

---

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===== ====== ===== The Last Psychiatrist: (Part 2) The Limits of Control: The Dream

...wait a second, these aren't matches, they're MacGuffins...

Part 1 here.

Once in a while we gather at a friend's house to watch a movie. We usually go to her house because it is the most inviting and comfortable, comforting; unlike mine, which is really only good for hiding POWs.. Her place, like her, is highly developed but but uncomplicated. Considerable taste but no knick knacks. No decorative soaps. When she's not working (sports reporter) she doesn't wear make up. She doesn't need to. She doesn't need clothes, either, but ignores this advice. Her (ex) boyfriend, whom I assume had a brain parasite, took 6 months terminally asphyxiate their relationship with a combination of weed, surfing, bartending and auditions.

This time I picked a movie I had read about: I picked The Limits Of Control.   She wasn't in the mood for a movie, but I had thought she needed a diversion. (Remember, I thought this was going to be an artsy G.I. Joe.)

Of course I was wrong. At about the first cafe scene I briefly fell asleep, then when I awoke a few minutes later I said, "what'd I miss?" and she said, "I filled your cup with strychnine."

Not only did she hate the movie, she couldn't stop telling us how much she hated it. For days afterward. "I am actually angry at the director for robbing me of part of my soul with that stupid, pointless, go nowhere movie. Boring! It was like having to listen to someone tell you their dream."

And then she added, with restrained fury: "This is Chuck's kind of movie."

II.

Freud was clear on two things: dreams are wish fulfillments, and they can only be interpreted using free association. There is no dream dictionary where flying means sex and cougars mean cougars.

Many elements of director Jim Jarmusch's movie are dream like: they draw from waking life, have their meaning stripped away and are then endowed with some other significance, specific to the dreamer.

For example, the title is derived from an essay with the same title by William Burroughs. But don't bother reading it because (quoting Jarmusch):

I don't know why. I love the title. The film does not, obviously, relate specifically to the essay--and I love that.

The two espressos, the shiny suits, "A Point Blank production"-- all are references to real events (or movies or books, etc) which you are tempted to link back to. Resist.   These aren't allusions to something; they are symbols for something else. It's not an episode of Lost. You can't understand their meaning by looking up the references.

The important thing is to say whatever comes to mind.

III.

Whenever a new "contact" approached the Lone Man, they would say, "you don't speak Spanish?" as a secret passphrase.   She thought this was stupid. "He's an African man in Spain, and he doesn't actually speak Spanish-- wouldn't you come up with a better code? It's like using "do you want fries with that?" at a McDonalds."

In the Freudian logic of dreams, an inability to do something-- being lost, stuck in traffic, something is missing-- represents contradiction. And when that inability is accompanied by a feeling of inability-- you're stuck to the floor, it's too heavy, you can't run-- it represents conflict of the will. So you just met a man and you're not sure about him, and you dream you're being chased by a powerful monster, but your feet are stuck to the ground and you can't run. It would mean you're conflicted about the monster (relationship.) But... but the dream as wish-fulfillment means you don't want to escape.

She lit up. "He's passive aggressive. He chose to go to Spain, but he doesn't know Spanish, so he has a convenient excuse not to have to listen to them. That's a classic Chuck maneuver.   There's always a reason why he can't be with you or give you his attention, but he yet he's totally dependent on others to tell him his next move or what to do next, he can't make major decisions on his own. So he waits for you to tell him, and then he picks and chooses what he hears."

"Was the 'two espressos' another kind of passphrase?" I ask.

"No, I feel like that was just posturing, trying to make himself seem unique. It's funny that he gets really mad at the waiter for not bringing him the right order, but he won't sleep with the naked woman."

"How are those related?"

"So, what, he has enough self control to resist sex, but not enough self control to be polite to the waiter?   He's a coward. What guy would not fuck a girl they found naked in their bed?   What is he, 15? Is he a virgin? She's not asking to get married, she just wants sex, just fuck her and get on with it. But he's so nervous around women he has to pretend he's a zen master? Maybe if he fucked her, he wouldn't care so much about how he got his espressos."

No one else would have made this interpretation. I'm almost certain Jarmusch didn't intend it either. But this was, after all, her dream.

"Wow, that is so much like Chuck, always playing the part of "I'll handle everything" but when it comes down to it... That's why he balled out the waiter. He can control himself, but it makes him crazy that he can't control other people or the world around him. So he creates all these rituals he has to do over and over to give himself the illusion of control."

I suggested Freud's interpretation, that repetition with variations (for example, the nude woman, then in a raincoat, then as a painting; the white castle, then a picture, then a statuette) represents a working through of some issue or idea; and that multiple symbols can be seen as working through the same issue in different ways. It clicked.

"That's what all Chuck's games are about, he wants everything exactly right, precise and perfect but that's so nothing ever changes, he never moves forward, he never evolves. Everything has to be by his schedule. Do you know he once said "not while I'm working" to me one time? He's a bartender, for Christ's sake."

So I asked, "why would Chuck want to kill Bill Murray?" Bill Murray plays a Dick Cheney character.   The Lone Man infiltrates his secret impenetrable bunker (not shown in the movie; "I used my imagination") and kills him.

"Bill Murray is his father, obviously. He's spent all this time working through his ambivalence about me and his job and everything else, he's finally mustered the courage to become his own man. Well, he wishes he did. He finally gets power over and he ultimately disposes of people that control him. I think a real father would want his son to stand up to him, because it means he's finally a man. That's why Bill Murray the father figure knows he's going to be killed but isn't scared, he doesn't fight or run.   And he says "you don't know how the world works" with no fear at all, just contempt. Which is actually the kind of thing his dad would say. I could see that Chuck wishes he could get out from under his father and grow up."

"And fuck you?"

"Too late for that," she said.

IV.

I'll repeat that I still thought the movie was boring. But now I'm not sure that matters. I think I am better for having seen it, my friend probably feels the same way. It has stayed with me and altered the way I look at other things.   In the final analysis, what Jarmusch intended is probably irrelevant: the important thing is to say whatever comes to mind.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: The Limits Of Control: The Movie

Hmm. Matches. Wow.

People will describe The Limits of Control in different ways, but inevitably using the phrase "worse than getting raped in the penis." That's typed correctly. I did manage to find three reviews that did not include that phrase:

"It's an art movie with almost no dialogue, action, or story, about characters with no names who are doing either nothing or something that you never get to understand. And it's long."

"Take an action movie, remove all of the action scenes and dialogue, and send straight to video."

"Biggest waste of time I have experienced since the Obama state of the union address."

Here's the IMDb synopsis:

The Limits of Control is the story of a mysterious loner, a stranger, whose activities remain meticulously outside the law. He is in the process of completing a job, yet he trusts no one, and his objectives are not initially divulged. His journey, paradoxically both intently focused and dreamlike, takes him not only across Spain but also through his own consciousness.

Don't ask me why, but this made me excited to think it would be a David Mamet redo of GI Joe: The Rise of Cobra. I was very mistaken. And I got retinoblastoma.

The main character is an iceman, highly focused on the job he was hired to do (which we don't understand.) He almost never displays emotion; he rarely talks. His face is made of concrete. Weird characters talk to him in cryptic sentences, pass him ciphers hidden in matchboxes which he reads, then eats. When he finds a naked billion (on a scale from one to ten, she's a billion) on his bed asking to have sex with him, he says, "never when I'm working." Control. He is frequently shown doing tai-chi, or staring at specific paintings in a museum: for focus. He always wears a suit when he is "working," day, night,sleeping, city, or in a desert.

That may sound like an excellent setup for a movie, except that there isn't any movie to go with it. None. Nothing happens in this movie, ever.

Here's a pivotal scene from the movie:

Now, it may be difficult to see from this photo what is actually happening, so I'll tell you: nothing. At all. I don't mean "nothing" as in "something, but it's boring," I mean nothing. For the whole scene. Let me emphasize again that this is a pivotal scene.

Here's a pivotal video clip:

You may raise an eyebrow: "hey, what are you trying to pull here, that's not a video clip, it's a still photo." Exactly. The Limits of Control isn't a movie, it's a series of photographs, each displayed for, oh, I don't know, 25 minutes each? and set to music. Bring blotter acid.

The movie seems to be offering you clues and hints about what's happening. I paused the movie on one of the ciphers to see if I could crack it, but I couldn't. I googled some of the phrases and images-- nothing. I wanted to figure it out, but couldn't.

The entire movie is populated with surreal images which beg for explanation, or at least a link to the haiku that passes for a script. No.

I have no idea what that building is, why he's looking at it, why he has a picture of it, and why it appears later on as a small statuette.

But, look, I don't own a North Face jacket, it's possible I'm just not hip enough to understand the symbolism. That turns out to be wishful thinking.

Example: Destro asks the waiter to bring him "two espressos-- in two separate cups." Hmm, intriguing. He's very emphatic about it, says it twice. But the waiter, who has to be deaf or retarded, instead brings him a double espresso. Destro yells at him, sends him back-- it's one of the only instances of emotion in the whole film. Hell, it's the only instance of action in the entire movie.

He does this, the ordering of two espressos, several times in the movie. This is framed and shot in such a way as to make its importance indisputable. So you say, ok, what gives? What is the relevance of two separate espressos? Is it a code, a signal? Is it an allusion to an Antonioni film, to Heidegger, what?

Turns out you are wasting your time: this isn't a symbol or clue, it was something that the actor actually did in real life, that the director, who was with him at the time, found funny. So he put it in the movie. "I found it amusing that he blew up at the guy." That's it. 'Art imitates life.'

Another example: the ending does have a sort of climax, but it's not obvious, so if you made it this far in the film you are paying close attention to everything, looking for some sort of explanation like it's the season finale of Lost. Why is does he change into that shirt? Why is he in an airport? Why is it green? etc.

In the last scene, the movie picture appears to jolt suddenly; the only way I can describe it is that it's as if the camera operator started putting the camera down before he turning it off.   What's the significance of that jolt? It's in such contrast to the stillness of the rest of the movie. Does it mean it's all a dream? He's killed? What? No, believe it or not, that jolt happens because the camera operator actually did put the camera down before he turned it off. And the director liked the effect.

I had to watch 27 Dresses with Katherine Heigl to detox from this atrocity, but then I ended up getting the bends. But that was the end of my involvement with this movie.

Well, it was until this happened.

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===== ====== ===== The Last Psychiatrist: The Lululemon Whydunnit

bad gamblers play not to lose

AP:

An employee at an upscale Maryland yoga clothing shop is accused of killing a co-worker who found suspected stolen merchandise in her bag, then trying to conceal the crime by tying herself up and blaming the attack on two masked men.

[Prosecutor] McCarthy said Brittany Norwood, 28, spun an elaborate ruse to convince authorities that she and the dead woman, Jayna Murray, had been attacked inside the Lululemon Athletica shop in Bethesda where they worked.

Terrible and tragic and etc, but at least intelligible, a linear internal logic. Norwood is stealing, gets caught by coworker and now has to make a decision: fold and lose everything, or go all in on one last hand and maybe get out of this.

That's the gamble: is it worth a life, is it worth going to jail forever, to get out of a retail theft charge? It is if it works, I guess.

II.

When you read enough news reports, you get to understand the code words. [Murder AND "upscale neighborhood"] always means domestic homicide (usually murder-suicide) or "non-white." Google it if you don't believe me.

The codes aren't conscious attempts to communicate unspeakable info to the reader, they are unconscious manifestations of the retinas of the writers. It's how they see the world, and after a while, you can tell how they see it by how they describe it.

"Make a left at the traffic light." "Make a left at the strip bar." Two different people.

So unless the two women were dating, this upscale neighborhood killing means one of them is going to be black or Asian. I leave the rest as an exercise for the reader.

III.

When Norwood was found the morning of March 12 inside the shop, she told police that she and Murray, 30, had been sexually assaulted by two masked men who came in the previous night after closing time. Norwood was found with minor scratches and other wounds, her hands and feet bound.
Trouble is, when they examine the women, there are no signs of rape. A week later they figure out it was Norwood.

[Prosecutor] McCarthy offered new details about what happened before Murray died, saying she had been asked by a store manager to check Norwood's bag for stolen merchandise. Murray called the manager that night to say she believed Norwood had been stealing.

That same night, after the store had closed, Norwood told Murray she needed to get back into the store because she left her wallet. When the two returned, they argued over the suspected theft, McCarthy said.
Norwood then picked up some sort of weapon inside the store and used it to beat Murray for as long as 20 minutes throughout the shop, McCarthy said. He said Murray sustained a severed spinal cord and blows "too numerous to count."

Oh, ok, it's this movie plot. Norwood didn't kill Murray to prevent her identity from being exposed, because Murray had already turned her in to the manager.   Norwood killed her later that night. Now it becomes a revenge story.   Still terrible, but at least it makes sense. Revenge taken as murder, and then Norwood stages the scene and concocts a story about masked men to trick everyone. So she's no longer going for four aces, she's trying to bluff. It's a longshot, but no one would wonder why you tried it.

IV.

Except-----------

When Norwood was found the morning of March 12 inside the shop...

-------except rather than leaving the store, rather than staging it as a robbery/murder and then getting the hell out of there so that no one would even think about her, Norwood stayed behind and pretended to have been a victim, too. She stayed there all night until the manager came to open the store the next morning.

That's not the behavior of someone trying to get away with something, that's the behavior of someone who wants to pretend to be someone else: I'm a victim. She thinks she can win, as long as she can trick you into going easy on her.

That's called a hustle, trying to convince seasoned players that you're someone that you're not. And when it fails, you get in a lot more trouble than if you just folded early and come back to play another day. Trouble is, hustlers don't hustle to win, they hustle because they don't know any other way to live.

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===== ====== ===== The Last Psychiatrist: The Maintenance Of Certification Exam As Fetish

no need to wait for the receipt

(I had reworked an old post for a psychiatry trade journal, which I would happily have linked you to, except that page 2 is behind a login wall. So here is the version I submitted before the editors edited it, slightly longer with more typos. I am posting this because of the new lawsuit against the American Board of Medical Specialties.)

The mission of the American Board of Psychiatry and Neurology's Maintenance of Certification (MOC) Program is

to advance the clinical practice of psychiatry and neurology by promoting the highest evidence-based guidelines and standards to ensure excellence in all areas of care and practice improvement.

That's what the website says, I have no reason to believe they are not earnest. But far from succeeding, the program does the exact opposite. We have come to a moment of truth in psychiatry, and we are all going to fail. By which I mean pass.

We can start with the 200 question certification exam. The most obvious clue that there was something suspicious going on with the test was that there were no questions about Xanax. How do you measure "excellence in all areas of care and practice" without asking about the most commonly prescribed medication in America, let alone psychiatry? Meanwhile there were several questions about pimozide, a medication which appears to be prescribed exclusively by psychiatrists who want to brag about prescribing it. I was repeatedly assessed on my competence in Dialectical Behavioral Therapy, but was not asked to display my knowledge of SSI. You might retort that SSI isn't really psychiatry, but then why is so much of my time spent on it? The only thing I spend more time on is Xanax.

But though the missing Xanax was a clue, the insidious problem with the exam was not the content. To see the bad faith obscured by the questions, put aside the usual college freshman complaints of, "why do we need to know about pimozide?" and ask instead, "what happens if I get the question wrong? What happens if I get them all wrong?" The answer is nothing. There are no consequences for failing this test, at all. First, 99% of the applicants pass, I assume the other 1% forgot to bring two forms of ID. Second, even if you fail, you can take it again and again, as many times as you feel it's worth the $1500. Third: there were a thousand easy ways to cheat, here are three: I could have walked out of the building on an unsupervised "break"; I could have Godfathered an ipad to the back of a toilet; or I could just picked up the phone and called everyone. Who was going to stop me? There is more security at a pregnancy test, which made me wonder if how easy it was to cheat wasn't... on purpose. The retort is that doctors are expected to behave honorably, but the honorable ones were going to pass anyway. Those in danger of failing-- the very people the test should detect-- would be most tempted to cheat. Doesn't the ease of cheating render the test unreliable? If the test is unreliable and 99% pass, why have a test at all? Which reveals the gimmick: the point of the test isn't to measure competence, but to convey the impression that competence was measured. The point of the test is to say that a test was given-- and nothing else.

The question is, to whom are we saying this? It is as if psychiatry was in denial about its ordinary reality and was trying to create a different identity through the test itself. A psychiatry where there are right and wrong answers. Where pimozide and Dialectical Behavioral Therapy happens, a lot. Let me anticipate your retorts: that the questions are carefully constructed for their validity; that the test itself "incentivizes" learning; that not everyone prescribes Xanax; that if I'm such a smartypants, what system would I use? If these are your replies, you have missed my point: a flawed system isn't better than no system at all, it is worse than no system at all, because at least with no system we are forced to be accountable to ourselves for our education. "Not everyone will be so dedicated." Correct, but now those same undedicated people get an official blessing of their ignorance. Who doesn't walk out of even this ridiculously meaningless exam not feeling smart, accomplished, up to date? And who would dare, after passing, to criticize the exam that warmed his ego?

In addition to the test, the Board also requires a nauseating number of CME credits, but these CMEs are an even worse affront to learning. The only thing that CMEs guarantee is that money was spent on buying them, $80 and no questions asked is all it takes, which is even sillier than it sounds since I could go to a number of websites which offer instant and unlimited free CMEs, so long as I skip the long text and just take the post-test, which I can take as many times as I want. I can get 1 CME every 25-50 seconds, depending on my ability to click "b".

The retort is that the system is predicated on a certain level of honor, that physicians shouldn't cheat. Fair enough, but if you're trusting them to be honest in revealing what they learn, why not simply trust that they're going to learn it? Because the point isn't the education. The CME exists to say that there is CME; the CME exists to say there is oversight.

To clarify: the important criticism here is not that the multimillion dollar CME industry is a gigantic money making scam, something on the level of the 15th century sale of indulgences, because to say that would be actually to defend that very system: the money is a diversion, a patsy, what is corrupt about CME isn't the money but, as the default mechanism for continuing education, it subverts its own purpose. It reduces the interest in actual education so that it can pretend that it explicitly monitors it. If you have a minute to spend on your "education," the system pushes you towards CME. "Why not do both?" Why do both, who can do both? There are only 24 hours in a day. In other words, the system doesn't just fail, it forces failure.

Last year there was a large cheating scandal at Harvard, over a hundred students were accused of plagiarism in a government class, and amidst the usual self-aggrandizing criticisms of the college kids as entitled, lazy, or stupid, what no one wondered is why, in an introductory survey course predicated on institutionalized grade inflation and no wrong answers, did the students feel compelled to cheat when they were all going to get As anyway? The terrifying answer is that they weren't cheating to get the right answer, there was no right answer, they were forced to cheat to concoct the answer the professor wanted-- because that's the system. Meanwhile, while they were spending their time "cheating", what real learning could be done? None. So--- why bother with an exam at all? Why not just offer the course and give everyone an A anyway? Because the purpose of the test is to say a test was given, to prove to some hypothetically gullible entity that learning occurred-- and to prove it to ourselves. Which is why our reflex was to criticize the kids, not the system: we are products of that system, to criticize the reliability, let alone validity, of that system would be to open ourselves to scrutiny, to deprive us of a core part of our own identity. "Things were a lot more rigorous when I went to college." First of all, they weren't. Second, even if they were, why, when you got to be in charge, did you change the system to this?

Seen this way, these tests, whether Harvard government exams or MOC exams, are nothing more than fetishes: a substitute for something missing which saves us from confronting the full impact of its absence. In less abstract terms, these tests allow us to believe NOT that we learned something, NOT that we know something-- but that there is something to know. Since there is nothing new to learn, therefore there must be a test. The logic of a 10 year MOC exam is to keep us up to date, so it's fair to ask: what in psychiatry has changed in ten years, what are the major advances? Depakote was discovered to be the default maintenance mood stabilizer despite no evidence supporting this, but that fell into disuse at a time oddly coinciding with its patent expiration, which is suspicious but I'm no epidemiologist. Anyway, it wasn't on the test. Anything else? A few new medicines have come out, though none of them appeared on the test either. There's money to be made on the west coast using giant magnets, (fortunately) also not on the test. So? Was the ABPN worried I'd forget how to use MAOIs? I'm never going to use them, I have enough problems monitoring Xanax. The astonishing truth is that despite millions of dollars and hundreds of academic careers psychiatry has made no progress in almost 20 years, let alone ten, a claim no other medical specialty can make, and the truth which cannot be spoken out loud. Hence an exam.

Are you prepared to look inside yourself? When a nurse practitioner asks you what about your board exam is difficult, what will you say? Take a minute, it's important. "Well, it has neurology in it." Note carefully that the psychiatry questions aren't "harder," the appeal here isn't to a higher level of expertise in psychiatry, but an expertise in something else, something "more" than psychiatry, and it is this link that symbolizes our status as "experts." Older psychiatrists will be quick to assert that "clinical judgment" counts for a lot, and I don't disagree, but it's probably not testable, and it most certainly wasn't tested. So what does $1500 buy you? "Existential support." I hope it was worth it.

What makes the MOC not just a bad exam but evidence of a pathology is that though college kids have no idea what they're up against, that the system works against their education, psychiatry is the very discipline that articulated these defense mechanisms. It should know better, it is supposed to know better; which means that we are either unable to see what we are doing or believe that we are somehow exempt from this. But here we are, spending time and money on cosmetics and pageantry to pretend that we are learning, to pretend that we are being measured, all the while slinging random neurochemicals + Xanax based on an a suspect but billable logic in the hope that something sticks and no one notices. Frantic activity as a defense against impotence. There is a term for that, but you can bet your career it won't be on the test. Pass.

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===== ====== ===== The Last Psychiatrist: The Massacre Of The Unicorns II

if it had a horn, I'm sure it would be a rhinoceros

There's a debate of sorts in psychiatry: to what extent should we rely on evidenced based medicine?

It's almost a trivial point-- we're going to rely on it anyway, why debate it? So the question should better be phrased, "to what extent should the future of psychiatry rely on evidence generated now?"

In a series of articles Nassir Ghaemi tries to justify Evidence Based Medicine in psychiatry; specifically, the primacy of evidence over theories or models.

Ghaemi's says clinical realities are more important than theories, and EBM allows for the study of clinical realities. Any deficiencies in the evidence-- confounding bias, diagnostic uncertainties, etc, are really a problem about the application of the studies, and not about the possibility of EBM in psychiatry. In other words, psychiatry is sound, but we need more and better data.

Ghaemi is arguing for an empiricist's approach, as opposed to a top-down theoretical approach-- one that starts with a theory, with concepts, and either ignores evidence or bends the evidence to conform to an existing theory. (His eg: psychoanalysis.)

II.

He asserts that the foundation is clinical observation, which is then studied further using scientific methods. For example, hormone replacement therapy done on thousands, later determined to be ineffective if not harmful. See? More evidence, better practice.

Hormone replacement therapy was the cure for many female illnesses. Decades of experience with millions of patients, huge observational studies with thousands of subjects, and the almost unanimous consensus of experts all came to naught when randomized studies proved the futility of the belief in that treatment (not to mention its carcinogenic harm).

A moment's reflection shows this argument to be illogical. Hormone replacement therapy did work. It had great risks, but to say that it was a failure is wrong. "It was the cure for many female illnesses, but..." So it was adequately tested in all of them, indicating its futility?

Ghaemi would respond that we would need more studies to determine the efficacy and risks in each indication, in each population. That would be right, but that's not what happened: doctors generalized the failure of a medication based on the outcomes in a restricted symptom set.

"Not better than placebo" is another false start. If a medication and a placebo both show a 25% response rate, it doesn't mean the drug is "no better than placebo": what if two different 25%s responded? Would the group that "responded" to the drug also have responded if crossed over to placebo?

The same is true for symptoms: if placebo and drug both result in a 25% reduction in symptom severity, it neither means the drug is a failure, nor, indeed, that the placebo is a placebo.

"Well, we'd need more and better studies." Of course. I'll wait at the bar.

III. Pay No Attention To The....

This story is apocryphal, so consider it a parable:

Pierre Eymard and friends were studying novel antieplieptics, and used dipropylacetic acid (a solvent) as both an intravenous vehicle for the drug, and as placebo. They observed that the placebo worked, too, preventing seizures at the higher concentrations.

If this had been a phenotype without visible effects, it would have been a perfectly ordinary conclusion that drug was not better than dipropylacetic acid-- aka Depakote.

"But placebos nowadays are inert." Is the fluorescent lighting in the office a placebo-- maybe it makes the anxious depressed patients more anxious? "Come on, those studies are from 1990." I guess that means the question had been satisfactorily resolved, requiring no further investigation?

"Well, more studies are needed..." Tell the bartender I take my rum straight.

IV. Improvement In Depression

Take the simple example of depression, as measured by the popular Hamilton Scale. The scale measures insomnia and weight loss, but not hypersomnia and weight gain.   Using this scale, a patient who sleeps too much and eats too much is less depressed than someone who sleeps too little and has lost weight. And, any drug that fixes sleep and makes you gain weight has an advantage over drugs that don't. In fact, a third to half of the improvement on the Hamilton could be accomplished by improved sleep and appetite alone. Go Zyprexa.

Note that the results of drug trials are reported only as total scores; you have no idea what symptoms the drug is fixing, or not. "But it's not powered to detect those effects." Ok, but it isn't designed to tell you if it's an "antidepressant," either; only if it lowers scores on the Hamilton in this single sample group.

"We need more studies, more scales."   But in the meantime we're left with "X is an effective antidepressant."

The standard academic line is that the evidence indicates all antidepressants are generally equally efficacious. Think about this. Have you ever met a single patient for whom that was true?

For a hundred reasons, none of that data applies to the patient sitting in front of you, yet it is the best information you have to go on. You have nothing else. Ok, go. The problem is not in the application of evidence to your patients, the problem is in the application of the theory that the evidence is creating in you onto your patient.

The Tohen data may show that Zyprexa is efficacious in depression, but when you prescribe it you are thinking, "antipsychotics in general are efficacious in depression in general, and I need a sedating one." You are doomed.

"But more studies are needed..." I look forward to reading them, or passing out, whichever comes first.

V.

That's the issue. In order for this to be a science, there has to be a testable hypothesis. There isn't any of that in psychiatry.

Example: antidepressant induced mania is the kind of testable question amenable to scientific investigation. Do they cause it, or not? But it's not easily answered, indeed, it cannot be answered. Which antidepressant? What's an "antidepressant?" Cymbalta, Pamelor, or Seroquel? Or CBT? What about semen? Which symptom of depression is it treating or not treating that allows you to call it an "antidepressant"?   You could do a billion studies on every drug ever made, in every description of "depression" imaginable and that would only allow you to say, "ah, I know the answer in a billion specific situations" but would still have no insights into the nature of the phenomenon.

Why don't all antidepressants cause it? "Well, there are exceptions to the rule." You've been infected: the rule is meaningless.

When you give someone Paxil, you are playing the odds: this worked in 25% of the guys we gave it to in 1997. There's nothing wrong with doing this, that's what you're supposed to do; but it does not allow you to speculate on either the nature "antidepressants" or "depression."

Simply put, the problem with "Evidenced Based Medicine" isn't the evidence, but the "based." Existing evidence can guide practice, but cannot be used to create a general practice model. "Mood stabilizers are the cornerstone of treatment in bipolar disorder." While I have no idea what you're talking about, I'm certain to be punished if I don't oblige.

In physics, such empty theories don't hurt anyone, and there's value in the theory itself. String theory may turn out to be wrong, but you at least are going to be really good at math. Okay.

But in psychiatry these empty questions and empty answers are still applied to social concepts as if they carried the weight of scientific validity. The question of "antidepressant induced mania" may be empty, but that doesn't stop the legal system from using it. You can't imagine the defense proposing that at the precise moment of the murder, the universe split into two equivalent eigenstates and the defendant, in this eigenstate, had been already determined to have had to have been committing the act of murder, which he already had even before he started; but that explanation carries considerably more scientific merit than the psychiatric one, by which I mean both have absolutely none at all. Wovon man nicht sprechen kann...

VI. Here There Must Be Dragons

"But you're not really arguing against the primacy of empirical evidence, you're arguing about the misapplication of that evidence. You're arguing against incorrect generalizations, against lumping data sets together to invent a clinical model."

No, it's much worse than that.

The problem isn't that the data is sound, but we shouldn't hastily extrapolate or generalize from that evidence. The problem is it is impossible not to do this.

The first reason is because of the use of words. "I met a blonde girl last night." Oh really? he replied knowingly. The words "depression" or "bipolar" or "antidepressant" all existed before we started using them. "Bi" and "anti" and "relapse vs. recurrence" all have connotations that may have no relevance to the way they are used now, yet those connotations will inevitably surface. It seems as though "evidence based medicine" has discovered that the antipsychotic Seroquel is also good for depression, but that's not science, it's an accident of history: 15 years ago the molecule could have been tested for depression, only to now be approved for psychosis. The evidence, the science, may be neutral on the drug's identity, but it will never be equivalent to an SSRI in your mind. In order for it to be successfully rebranded, everyone who learned it the other way has to die.

Second, the explicit purpose of psychiatry is to apply the discoveries immediately. The hasty generalizations and applications aren't a byproduct of the field, they're the whole point. We don't have time to wait for a physiological explanation for bipolar, we have to get people better now. But while extrapolating from "kindling theory" or one antiepileptic's mania data to a theory of "mood stabilization" is a noble attempt, it's still wrong.

Third, our brains have no alternative but to assume causality. No matter how many times you say "X is associated with Y" we will think "X causes Y." Academics like to point this mistake out when residents do it, but everyone is guilty of it, all the time. This isn't a criticism of human laziness, this is how we're designed. Our brains can't help it, they do not allow for a vacuum, they force causality. The brain may not let it become conscious, but you'll act like it, breathe like it. Even when you know it's wrong. I know how a mobile phone works, yet I still yell louder when it starts breaking up. The only way to stop assuming one explanation is to be given another explanation.

Fourth, while 1 + (-1) = 0, a positive study is never completely refuted by a negative one-- and vise versa. Even if studies are of identical design in the exact same patients, the marketing of a study-- who wrote it, where it was published, how many "thought leaders" got behind it, how many pages, tables-- all of this supersedes the content. Even if you successfully appraise a single study on its merits, the rest of the vastness of psychiatric literature is available to you only by rumor. When the fashion turns away from SSRIs and North Face jackets, you'll frown when they occasionally reappear.

Fifth, simply asking the question often overwhelms the evidence. If you ask, "does Geodon cause QTc prolongation?" it immediately stops mattering whether the evidence shows conclusively that it doesn't, or that it was a mistake; it even stops mattering whether you even understand what "QTc prolongation" means. The moment the question is asked, you are forever condemned to pause before prescribing Geodon.

VII.

I've avoided discussions about groupthink or specific biases in studies as they are incidental to the fundamental problem of psychiatry, which is a faith in the primacy of evidence in the absence of any interest in a theory of mind. Evidence can, should, and does inform practice, and none of its shortcomings should change the way we use it today. But faith in evidence hasn't moved psychiatry forward at all in 50 years. More evidence will not fix this, because there's nothing guiding the evidence.

The unfortunate truth is that most of the evidence in "evidenced based medicine" is at best too limited for general application, at worst wrong. Many of you will reflexively recoil from this, retreating from the vertigo to the crowded safety of your peers, journals, and false idols, but this empiricism is only another kind of apostasy. Repent.

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===== ====== ===== The Last Psychiatrist: The Media Is The Message, And The Message Is You're An Idiot
(From The New Yorker)

You mean I get to pick?

I. What Is Real?

This is the story of the real John McCain, the one who has been hiding in plain sight.

This is the kind of sentence that you expect from a Woodward and Bernstein after months in dark parking garages, or maybe a book based on the results of secret CIA documents, but unfortunately it appears in Rolling Stone. The piece is called, Make Believe Maverick, i.e. pretending to be cutting edge and independent, a voice of the people, and not really the arm of Big Business which he will here be revealed to be. I hope someone else appreciates the irony there.

There's also a piece called The Truth About Palin: A guide to separating myth from fact.   (Where does one place the sic?) And even a video "Five Myths About John McCain" which are sure to surprise you, like "John is a straight talking reformer" and "John is a Washington outsider." One shot shows a photo of him seated at a desk, reaching out to take someone's off screen hand. The camera slowly pans left across the photo to reveal--- Ronald Reagan!

Truly these are the end of days.

Oh-- all three pieces are buy the same guy.

II. Go To The Source

What is naked shorting? Don't know? You could look it up on Wikipedia, where it says a great number of things, except that it is bad. That it could be bad-- by artificially depressing a stock's price-- is hotly debated everywhere-- except on Wikipedia. Know why? Because, Gary Weiss-- who may (or may not) have worked for/used a computer at the Depository Trust & Clearing Corporation which oversees stock settlement, became a Wikipedia editor and effectively controlled the entry. He also derided the CEO of Overstock.com, Patrick Byrne, who was vocally against the practice, by blocking his edits and even controlling his (Byrne's) Wikipedia page.

The story would be more interesting if Gary Weiss turned out to be a former journalist at BusinessWeek, where he should have learned not to manipulate the truth, as well as understand the effects of naked short selling. Well, he was.

The debate here is not wheither Byrne or Weiss is right-- whether naked short selling does drive stock prices down, creating more volatility (it does.) The question here is this: if Wikipedia can be edited by anyone, why wasn't the entry "fixed?" Leading to the second question, since it is obvious that it can't really be edited (effectively) by just anyone, how do you get chosen to be the main guy? If the CEO of an $800M company isn't allowed to write a few lines, what chance does anyone else have?

III. Psychiatry Finds The Truth

Do you know what antidepressant induced mania is?   For ten years I've been yelling at anyone who would listen that it doesn't exist. Let me caveat that: "exist" isn't the word I took issue with, the word was "antidepressant": how can you blame an entire group of chemicals that many times have no similarities at all (Prozac vs. Wellbutrin) as having the same rare side effects? That's classism, right?

I wrote a number of "scientific" articles on the subject, and only one was ever published-- the one in which I described a scenario where it actually did happen. For reference, I've published many other articles, so the problem here wasn't my writing or research, it was my stance.

So when someone writes an article agreeing that antidepressant induced mania is overstated, I read it closely-- not for new information, but because I want to see how he got it past the censors.

In a section entitled What is the Best Available Evidence? the author writes,

More conclusive evidence can be derived from two recent, large controlled studies, one being a monotherapy study,⁴ the other a study investigating the combination of a mood stabilizer and the choice of two antidepressants.⁶

I knew immediately what the second study was; but I hadn't ever heard of the first-- a monotherapy study with an antidepressant in bipolar, controlled and large? Am I slacking? Oh, it's a Seroquel study.

IV. Your Thoughts Have Been Peer-Reviewed, and Badly

And it beceoms clear that all media are peer -reviewed, and by peer-review I mean not you or your peers. Rolling Stone is so tight it has the same idiot generate three different pieces for the same issue. Same with anything else.

It is the same guys, over and over again, each in their own space, and by default we assume they are the most knowledgeable, or the most rigorous; have the most information or are best able to remain objective. Or maybe we simply hope they'll be good enough.

But having the same guys means that we'll be getting the same philosophies, the same filters, the same phrases. We are guaranteeing not just groupthink, but we're allowing others to decide what we're going to talk about, how we'll talk about it. That's why "gay marriage" will disappear not when gays can marry but when a new set of media people get jobs and "gay marriage" isn't as interesting to them. The actual importance of "gay marriage" in the world is not at all the important question-- it may be extremely relevant, or not at all, but that's irrelevant. Why we're stuck with "bipolar disorder" until, I don't know, the neo-analysts return with their talk of "repressed thyroid energy" or something, but emphatically not because we discover anything qualitatively new about bipolar.

And so it goes. If you wonder why you seem ADHD or anxious, it may be that you are being told certain things are horribly important, yet you can't seem to feel it; meanwhile you are also being told the things you thought were important are trivial.

And the only place (you are told) you can go to regain balance is psychiatry. Good luck with all that.

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===== ====== ===== The Last Psychiatrist: The Military And PTSD: A Star Wars Guide

In The Empire Strikes Back, the Millennium Falcon is being pursued by Imperial Star Destroyers and several TIE fighters.

Something hits the Falcon. "That's not a laser blast..." says Han.

"Asteroids!" yells Leia from the cockpit. They are everywhere. She quickly gets up to allow Han to take control.

He makes a snap decision. "Chewie, set 271."

She didn't expect him to say that. "What are you doing?.... You're not actually going into an asteroid field, are you?"

"They'd be crazy to follow us, wouldn't they?"

Han Solo deftly turns and flips the ship, trying to doge the both the asteroids and the laser blasts from the remaining TIE fighters. Leia, Chewie and C3PO stare powerlessly as asteroid after asteroid almost obliterates them.

It becomes obvious to all that this was a terrible idea.

"You said you wanted to be around when I made a mistake," Solo deadpans. "Well, this could be it."

"I take it back....we're going to get pulverized if we stay out here any longer!" Leia says.

"Can't argue with you there. I'm going in closer to one of the big ones."

"Closer?!"

Take a good look at the expressions on their faces. Solo focused, almost angry. Leia terrified. Chewbacca fearful and incredulous.

This is a kind of exposition, the character's personalities being revealed through a trial.

They all come out ok, but let's say they didn't. Excepting the metallic version of Professor Smith, who there is most likely to get PTSD?

Chewbacca is an ex-soldier who has seen all kinds of war horrors. Leia's been tortured, seen her home planet be destroyed, been in gun fights, so it's not like she hasn't been stressed. But looking at their faces, it's evident that they are more terrified, there's something about Solo that lets him manage his fear and his response to it. Genetics? Toughness derived from years of hardships? Alcohol?

It may not be any of these things. It may simply be that Han Solo is driving.

II.

Thanks to a reader, 2LT Timlin for turning me on to Sebastian Junger's War, a book I had never heard of and which apparently no one in the military has either.

The Navy study compared stress levels of the pilots [who have to land on tiny aircraft carrier landing strips] to that of their radar intercept officers, who sat immediately behind them but had no control over the two-man aircraft. The experiment involved taking [cortisol] samples of both men on no-mission days as well as immediately after carrier landings... Radar intercept officers lived day-to-day with higher levels of stress -- possibly due to the fact that their fate was in someone else's hands -- but on mission days the pilots' stress levels were far higher. The huge responsibility borne by the pilots gave them an ease of mind on their days off that they paid for when actually landing the plane.

The study was duplicated in 1966 with a twelve-man Special Forces team in an isolated camp near the Cambodian border in South Vietnam... There was a serious possibility that the base would be overrun, in which case it was generally accepted that it would be "every man for himself." The two officers saw their cortisol levels climb steadily until the day of the expected attack and then diminish as it failed to materialize. Among the enlisted men, however, the stress levels were exactly the opposite: their cortisol levels dropped as the attack drew near, and then started to rise when it became clear that they weren't going to get hit... "The members of this Special Forces team demonstrated an overwhelming emphasis on self-reliance, often to the point of omnipotence," they wrote. "These subjects were action-oriented individuals who characteristically spent little time in introspection. Their response to any environmental threat was to engage in a furor of activity which rapidly dissipated the developing tension."

Specifically, the men strung C-wire and laid additional mines around the perimeter of the base. It was something they knew how to do and were good at, and the very act of doing it calmed their nerves. In a way that few civilians could understand, they were more at ease facing a known threat than languishing in the tropical heat facing an unknown one.

Two things to note: one is the perception of powerlessness as a factor in stress; the other is that action is useful for its own sake. Action according to logic or training can be empowering even if it is itself purposeless.

III.

Junger starts his book with this epigraph, from Lord Moran's Anatomy of Courage:

By cowardice I do not mean fear. Cowardice... is a label we reserve for something a man does. What passes through his mind is his own affair.
The quote is popular all over the internet, but it's a misquote. This version conveys the impression that everyone feels fear, but only a coward acts on it.

By cowardice I do not mean fear. Fear is the response of the instinct of self preservation to danger. It is only morbid, as Aristotle taught, when it is out of proportion to the degree of the danger. In invincible fear-- 'fear stronger than I am'-- the soldier has to struggle with a flood of emotion; he is made that way. But fear even when morbid is not cowardice. That is a label we reserve for something that a man does. What passes through his mind is his own affair.
The forces that go into creating cowardice were often outside of the coward's control. He probably didn't want to be a coward; he wasn't trained not to be.

IV.

One of the most puzzling things about fear is that it is only loosely related to the level of danger. During World War II, several airborne units that experienced some of the fiercest fighting of the war also reported some of the lowest psychiatric casualty rates in the U.S. military. Combat units typically suffer one psychiatric casualty for every physical one, and during Israel's Yom Kippur War of 1973, frontline casualty rates were roughly consistent with that ratio. But Israeli logistics units, which were subject to far less danger, suffered three psychiatric cases for every physical one. And even frontline troops showed enormous variation in their rate of psychological breakdown. Because many Israeli officers literally led from the front, they were four times more likely to be killed or wounded than their men were -- and yet they suffered one-fifth the rate of psychological collapse. The primary factor determining breakdown in combat does not appear to be the objective level of danger so much as the feeling -- even the illusion -- of control. Highly trained men in extraordinarily dangerous circumstances are less likely to break down than untrained men in little danger.

The division between those who feel in control of their fate and those who don't can occur even within the same close-knit group. During World War II, British and American bomber crews experienced casualty rates as high as 70 percent over the course of their tour; they effectively flew missions until they were killed. On those planes, pilots reported experiencing less fear than their turret gunners, who were crucial to operations but had no direct control over the aircraft. Fighter pilots, who suffered casualty rates almost as high as bomber crews, nevertheless reported extremely low levels of fear. They were both highly trained and entirely in control of their own fate, and that allowed them to ignore the statistical reality that they had only a fifty-fifty chance of surviving their tour.
Note again the relationship of the feeling of control-- not the actual possession of control-- to the reduction of fear.

And note the wording of the last sentence: "allowed them to ignore... reality."

IV.

Marshall McLuhan once said, "if everything around you is a nail, then get a really strong hammer." So the psychodynamic hammer: if narcissism is the exertion of will towards the maintenance of ego-- trying to get everyone to see you the way you want to be seen, and to get them to act the way you need them to act-- then a narcissistic injury would be the discovery of the limitations of your own power.

If the Americanized culture of the past two generations has deliberately encouraged narcissism as a positive personality structure, then we can expect higher rates of PTSD than in WWII not because the physical stresses are more severe-- in fact, they are most often less severe-- but because the discovery of the limitations of our own power shock us more deeply than it shocked them.

Typically, avoidance and flashbacks are the proxies for the diagnosis of PTSD, but these are drawn from experience with soldiers from a different time and a different culture. Today, the primary symptom of a traumatic reaction to the discovery of powerlessness wouldn't be fear but rage. Hence, new onset domestic violence is more sensitive than nightmares. "Being there" (suddenly staring off into the distance) more specific than reliving the traumatic event.

It follows that a PTSD soldier at home would be much less traumatized by a terrible car accident than by the suspicion that his wife is cheating.

IVb.

I'm not saying soldiers are narcissists; but that's the culture we were taught from the day of our birth. The military should have made an effort to understand the psychic vulnerabilities of the culture it was recruiting from, and adjusted its training to anticipate those vulnerabilities.

More broadly, a nation that chooses to go to war-- for good reasons or bad-- should train its population to be more selfless, to establish as obvious that each person is merely part of a far more important whole, and to incentivize displays of that thinking with explicit rewards.

and you wonder why there are no other Wookies in V and VI

If it cannot do this, if it can't institutionalize this, it shouldn't go to war, most practically because it will not win.

V.

I wasn't so young 30 years ago that I shouldn't have known better.

After Vader tells Luke he is his father, he implores Luke to join him, "together we can rule the galaxy!" etc.

I remember thinking, why doesn't Luke just lie? Why doesn't he just pretend to join Vader, and then light saber him in the head or poison his rebreather later on? Instead, he jumps like a Stoic.

Short term yes, long term no. Turns out Lucas/Campbell was right and I was wrong. In extreme scenarios, for example torture or being a prisoner of war, lying and pretending gives short term gain but accelerates your mental breakdown. People who have survived have done so not by toughing it out-- me vs. you-- but focusing on something they considered more important than their own survival. "This hurts, but it's far better than bowing down to them."

In the language of learned helplessness: there is a vicarious learning in watching yourself apparently break down and give them what they want. Furthermore, it reveals the limits of your power: I had no other options but acquiescence.

The military's immediate problem is that this advice must now be learned in adulthood; there hasn't been 20 years of practice. It is not reflexive; narcissism is. I hope it requires no elaboration that the people we are currently fighting have exactly the opposite circumstance.

IV.

Many of the solutions propose themselves, but with respect to the military, and any organization that rises or falls on the tenacity and relentlessness of its members, Lord Moran offers this generally unpalatable perspective:

Leadership only concerns me when it hastens or delays the using up of a soldier's will power. But discipline runs through this part of my book like an undertone. Men are everywhere demanding whether a discipline which was designed for the illiterate is still suitable for an army with considerable number of thinking men in its ranks. I have turned over in my mind whether it is possible to relax that discipline without impairing a soldier's efficiency as a fighting man, and I can only find one answer...

The answer is no.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: The Moral Hazard

(This is Part 2-- click to read Part 1)
If you behave badly because you know you'll get away with it, that's being "bad."
A Moral Hazard is different. If you behave "worse" than you would have otherwise, solely because you know that you won't have to bear the consequences, then you have a Moral Hazard.
I'll emphasize: the key is that your behavior is in itself not necessarily "bad." It is simply worse than your behavior otherwise would have been, because you know there won't be consequences.
Here's why it's called a Moral Hazard: if there are no external consequences, the only thing that would prevent you from behaving worse is an internal set of rules.
Where do these internal rules come from?

Let's run some examples, starting with the current credit problem:
Too much risk (credit) got the hedge funds (and us) in trouble. If Bernanke lowers rates to save the economy, and thus inadvertently bails them out, the hedge funds have learned they can take bigger risks next time, because they know Bernanke will (inadvertently) bail them out again. It’s not that Bernanke wants to bail them out, he doesn’t. He wants to save the economy—but the hedge funds now know he will repeatedly do this and can act “worse.”
Insurance: If you have no car insurance, you drive very, very, very carefully.   The Moral Hazard describes when a person, upon getting insurance, drives “worse” (read: less slowly, rolling stops; doesn’t avoid talking on cell phone.) NB: he is not driving badly; he is actually driving normally. But he's driving worse than "very carefully." The term “worse” is relative to other behavior. The point is that his behavior has comparatively worsened because he doesn’t have to worry as much about the consequences.
Moral Hazard is cited everywhere in the universal healthcare debates: if healthcare is free, people may be less attentive to preventative measures, or overuse medical care. Before you scoff, imagine behavior if you had to bear all the cost personally. To counter the Moral Hazard, we have limits, deductibles, co-pays, etc.
A subtype of the Moral Hazard is the principal-agent problem, in which one party has more information/knowledge they can use to maximize their own benefit.   A doctor, having considerably more information/knowledge than a patient, can use it to maximize his benefit, not even necessarily at the expense of the patient. For example, he could bill for an extra service. He can ask the patient to return more often than necessary to get the extra visit fee, perform unnecessary tests, etc. So, too, lawyers, and politicians, etc.
A more interesting example is the doctors who recommend a treatment modality-- for example, Depakote for maintenance bipolar--because it furthers their career, though it may not be as effiacious as another modality or more toxic.
People invoke the Moral Hazard to complain about easy bankruptcy laws: if there are no consequences to declaring bankruptcy, people could borrow excessively and then simply walk away.

But what causes the Moral Hazard? Why do all people, to varying degrees, fall prey to different forms of the Moral Hazard? Why, and to what extent, does behavior worsen when there are no consequences?
Causes of the Moral Hazard

Succumbing to the Moral Hazard means that you have priced your gain above the loss of the other. Let me be clearly emphatic: your gain is priced not above the gain of the other, but specifically above the loss of the other. That's what makes it a Moral Hazard, and not an economic or strategic hazard. They know their actions cause a harm to the other, but do it anyway.
So the real question is, what makes people not care? Let's be clear that I am not talking about evil; I'm talking about the context dependent decisions of gain vs. loss.
There are two cases:
The loss is determined to comparatively trivial. The inattentive insured driver knows that insurance rates will be raised, but he figures he himself only caused a tiny part of that raise, which is considerably outweighed by his gain of getting to use a cell phone in the car. Similarly, each individual hedge fund figures it contributes very little to the overall risk cycle.
Unknown sufferer. While it is necessary that someone suffer some loss, it is not necessary that the specific identity of that someone be known. In fact, not knowing the specific identity makes it that much easier to find in favor of your gain, that much easier to be seduced by the Moral Hazard.
It's case 2 that is the psychiatrically interesting one. What about when the person harmed is clearly identified? How do you facilitate, psychologically, the harming of that person? The answer, of course, is to strip that person of their individuality, and see them only as an extension of you, your situation.
And so we return to it.
The Moral Hazard and Narcissism
The Moral Hazard is narcissism.   The degree to which one is susceptible to the Moral Hazard is the measure of the individual's narcissism.
Remember, this isn't about evil; it's about what psychic variables make "your gain vs. their loss" calculations easier or harder to solve.
In an extreme case where a clearly identifiable person is greatly injured—say, a doctor who prescribes chemotherapy to a non-cancerous patient just to collect fees—the person can act precisely because he fails (or chooses not) to see the person as a separate entity—he only sees the person as it impacts himself.
The Simpsons' Mr. Burns used to refer to his employees as "organ banks." That's narcissism.

The Moral Hazard is, in essence, the opposite of Kant's categorical imperative.
So the causes of Moral Hazard are the degree to which a person

is able to see others as individuals and not only as they impact himself;
has an internalized set of rules that do not change regardless of how it impacts himself.
Everyone has a level of narcissism, thus, everyone faces Moral Hazards.
It's not that only narcissists fall prey to Moral Hazards; it's that narcissism is what allows you to see a Moral Hazard, where others don't. Consider the principal-agent problem: Say you're a lawyer. You could easily bill for an extra hour, no one would know. Ok: did that ever occur to you?
So the variables all impact your response to a Moral Hazard, and are covariant: your level of narcissism; your gain vs. their loss; the identity of the person harmed, etc.

The Application of the Moral Hazard to Others
But an even better description of the relation of narcissism to Moral Hazard is how your behavior creates a Moral Hazard for others.
A good example is parenting. If a three year old throws a tantrum, you can either appropriately deal with it, or give in to it. But if you give in, you know the kid will throw a bigger tantrum next time, because he has learned there won't be any repercussions. There are two things you want: you want to teach him that these rules will be consistently applied, "so don't try to get away with it;" but, more importantly, that rules in general are consistently applied, so learn the rules and internalize them, with no consideration of your own gain-- don't try to calculate if you can get away with it, even if you can get away with it. That second lesson is how you prevent (reduce) narcissism.
So good parenting requires that you always address tantrums in the same way-- consistently. Eventually, he internalizes the rules, they become part of his personality. You have thus averted his facing Moral Hazard; you have saved him from narcissism.
But now you're in a store and he throws a tantrum. The Moral Hazard still applies, but there's a new variable: your embarrassment. Do you deal with the tantrum the same way as at home, or do you give in-- stick a cookie in his mouth, buy the toy, whatever-- just to shut him up, hoping to deal with it back home? Clearly, the latter likely reinforces bad behavior. You know this. What do you do?
Do you teach him rules are rules, no matter where and what-- save him from narcissism; or do you let him slide this time and reinforce that rules are context dependent-- in essence, reinforce his narcissism?
How you teach your kid about the Moral Hazard is, in fact, your own personal Moral Hazard: do you gain a little at the store, at a loss to his development?
Now you can see how your creating Moral Hazards for other people reflect your degree of narcissism. Let's say it's a fact that free auto insurance leads to worse driving. If you are a politician who votes for free auto insurance because you will gain in popularity, knowing that it causes a Moral Hazard for others which is to the loss of still others, then you have double the narcissism.
(Read Part 3 . The markets are stable today, and GOOG is up, thank God.)

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===== ====== ===== The Last Psychiatrist: The Most Important Article On Psychiatry You Will Ever Read

I'm warning you.

Let's begin with a simple drive down a country road, say, I10.

The Three Problems of Psychiatry:

You know those white dashed lines separating the lanes in a highway? How long are they? Answer: _____________ Most people I ask say 3 feet. The real answer is 10 feet. Surprised? And that’s the first problem in psychiatry: perspective. Your perspective is always driving at 60mph, so they look 3 feet long. Unless you change your perspective, you never get to see the truth. Worse, much worse, you go through life confident they are three feet.

Which brings us to the second problem: closed mindedness. Even though I’ve told you the truth, you still don’t believe it—that’s how powerful your perspective is. “He must be talking about some other lines, maybe in France?” Unless you change your perspective, you will never be open to the truth, to the discovery that what you have thought, for your entire life, is wrong. Unless you get out of your car and measure those lines, you’ll never accept the truth.

Which brings us to the third problem: if you do try and change your perspective, get out and measure those lines, you will be quickly dispatched by a minivan to the face for your lack of faith.

The irony of it all was not lost on Paris. Or was it coincidence? Irony?

Here is a picture of a molecule of Seroquel:

It’s a single molecule. Count them.

Seroquel, like all atypical antipsychotics, binds to multiple receptor types. Seroquel blocks, with varying affinity, histamine (H1), alpha 1 (a1), dopamine (D2), etc, etc. You can imagine a molecule having different spokes to it, that each bind to different receptors. Here’s a graphical representation of this, made famous by Steven Stahl, MD, at the University of California, and formerly with Styx:

Consult your doctor if you are at risk for esophageal rupture

The other way this is often represented is with a pie chart:

From the video Serocool (Styx, 1981)

A typical understanding of this pie chart is that the various sizes represent “amounts” of blockade. So, here, Seroquel is very antihistaminergic—so it causes a lot of sedation. It is moderately an alpha1 blocker—which is what causes orthostasis (lightheadedness/dizziness/grogginess). And much less of a D2 blocker, which is what actually provides the antipsychotic effect. You can also see that Seroquel’s H1 section is bigger than Zyprexa’s, which explains why Seroquel is more sedating than Zyprexa. (1)

One molecule gets you H1, a1, 5HT2a, D2

Two molecules gets you twice as much H1, a1, 5HT2a, D2

So this is so easy to visualize that anyone can understand it. But unfortunately this representation is misleading, it leads you to think something that is not completely accurate, in the same way that looking at Nancy Pelosi makes you think of that guy in Raiders of the Lost Ark:

BUT HOW CAN COLOR PICTURES BE WRONG?
One of the central themes of the postmodern critique of our values is that aesthetics must trump truth as long as aesthetics remains undefined. That’s the semiotic conundrum, why psychiatry is politics: the truth is demanded only when it supports a preset ideology.

WHAT THE HELL ARE YOU TALKING ABOUT?
Nothing. Let’s move on.

The mistake is that those pie chart sections aren’t amounts, they are affinities. They are preferences. Here's a metaphor. Imagine you have only one molecule of Seroquel. Where does one single molecule prefer to go? It can’t go to four different places, right? It has to "choose." And most likely it chooses to go to H1. The spokes don't cause the effect-- the spokes fit into receptors-- the receptor causes the effect. So if it binds to H1 receptor, the other spokes remain unused.

Let’s say you are a gentleman, and as such prefer blondes by virtue of their fair hair, lithe contouring, and receptiveness to new ideas. If you’re in a room with 10 brunettes and two blondes, do you go to everyone, equally? (Assume for this gedankenexperiment you have only the one, non-mechanical penis.) No, you make a bee line for the blondes.

Tom was thankful he was sober enough to avoid the ugly one

WHAT IF ALL THE BLONDES ARE TAKEN?
This is a safe bet. Sadly, since not every blonde will support your ideas for a ménage, you’ll have to settle for the brunettes. Painful, I know. I can call you in a script for Viagra.
So one molecule goes to H1. What about two molecules? Or three? Or 13 gazillion?
Think how sedating 25mg of Seroquel is (trust me, it's sedating.) Why isn't 32 times more-- 800mg-- lethal? Certainly 32mg of Xanax is more than a short nap, so what's the difference?

Instead of thinking that the drug binds to all receptors simultaneously, a better analogy would be a champagne fountain, like at a wedding. Except I hate champagne, so pretend it is a rum fountain. Rum fills the top level, overflows into the second level, then that overflows into the third, etc. You can't get anything into level 3 until you fill levels 1 and 2. And, once you've filled level 1, you can't put anything more into it.

Get it? So level one can be labeled H1, level two is alpha 1, and level 3 is D2. (2)
So you can see that, at some dose, there is no more increasing sedation with Seroquel. You've filled up level 1-- the H1 section. Going from 25mg to 50mg is a big jump in sedation (level 1), but going from 400mg (level 3) to 800mg is not felt to be an increase in sedation. It's the same amount of sedation, because by the time you hit 400mg, you were all full up. (3)
But there’s a dark side to my analogy, and it isn’t the rum fits. Here’s the thing: if one molecule of Seroquel goes to H1, and not to D2, then can it have any antipsychotic effect? No. One molecule binds to H1, so it isn't an antipsychotic, it's an antihistamine.

DOESN’T THE BOX CLEARLY SAY ANTIPSYCHOTIC?
Yes, it does. Weird, isn’t it?
Until this drug is blocking a significant number of D2 receptors, it is not functioning as an antipsychotic. Important: the antipsychotic effect of one molecule of Seroquel isn't so weak you just can't see it-- it is exactly and precisely zero.
The drug can't be called an antipsychotic unless it is behaving as an antipsychotic, regardless of the product labeling.

ARE YOU SAYING THE FDA ARE A BUNCH OF UNSCIENTIFIC ASS-MONKEYS?
What?

At some amount of D2 blockade, these things will be antipsychotics. What amount? Theories abound, but look at it this way: 10mg of Zyprexa blocks a certain number of D2 receptors. How much Seroquel, Risperdal, or Geodon does it take to block the same number? Answer:
10mg Zyprexa = 500mg Seroquel = 3mg Risperdal= 120mg Geodon. (4)

This is the problem so many doctors have. “I tried him on Seroquel, it didn’t work.” Really? At what dose?   Because higher doses aren’t stronger—they are completely different. The behavior of Seroquel at 100mg is completely different than the behavior and effects at 500mg. 500mg is an antipsychotic; 100mg is not an antipsychotic. I know it looks like it’s five times more, but it’s not—it’s the addition of a completely new level. It's like adding a new “drug.” Just because the FDA calls it an antipsychotic, and that word is printed on the box, doesn't mean it is.

DOES THAT MEAN 5mg ZYPREXA = 250mg SEROQUEL?

So you weren’t listening.

Reducing these doses by half pretty much extinguishes the D2 blockade. Reducing the dose puts you into a different "level." They’re not half as good as they were, they’re completely different.

The drug isn't a tease. It doesn’t give you a little bit of efficacy at a low dose, “oh, it’s working a little bit—he must be a Seroquel responder—I’ll just increase the dose to get more efficacy.” Another way of saying it is this: the absence of efficacy at 250mg is in no way predictive of what might happen at 500mg, because the two doses are working at different receptors.

So, yes, 5mg Zyprexa is equal to 250mg Seroquel for psychosis, in the same way that an academic psychiatrist is like a certain Congresswoman from California: they all do nothing. ZING! (5)

Next up: Oh, No, Not Effexor, Too?

----------------------------------
1. The pie chart is wrong, wrong in the same way that Pamela Anderson is wrong, i.e. right in many ways. This is an in vitro pie chart, derived from affinities of receptors ripped out of the cadaverous remains of former tax attorneys. It may not represent what happens in an actual human body when confronted with unequal distribution of drug and receptors, number, and subtypes of receptors. It also doesn’t account for competition from other endogenous chemicals, drugs, or ice picks in the skull. All this notwithstanding, they are still usefully inaccurate. And all this is just a metaphor anyway.

2. This is not technically accurate. Receptor systems don’t fill up, i.e. become saturated, before the next system is impacted. More accurately, there exists a certain level of binding at one receptor such that it then becomes equally likely that it goes elsewhere. So my rum fountain should be more accurately labeled “the effects from H1 blockade” and “the effects from alpha 1 blockade.” Those effects do “max out.” Also, a drug’s maximal effect can occur well before 100% saturation of a system; for example, 10% H1 blockade may be all that is necessary to get maximal sedation, such that increasing binding to 20% doesn’t get you more effect. Nor might a drug be able to bind to more than 10%. So while binding saturation is often used interchangeably with maximal effect, they are not the same.

3. Drugs bind to specific receptors, but also nonspecifically (i.e. everywhere else.)

Note that binding is related to the rates of the binding (Kd=Koff/kon)

If you want a real world example, look at Zyprexa, below-- a real human in a real PET scanner eating real Zyprexa:

If you increase the dose from 5mg to 30mg, serotonin binding increases from 95% to 100%. Do you expect to “feel” much difference? But D2 binding goes from 55% to 85%. That you’ll feel.)

4. Be careful: these are the equivalents for D2 blockade—for antipsychosis. If you are using Zyprexa for, say, anxiety, then maybe D2 isn’t the relevant system. Maybe it’s the serotonin that’s relevant. (I have no idea; NO ONE HAS ANY IDEA.) So the conversion doesn’t hold. Do you understand? If you are using 10mg Zyprexa tablets to clog a toilet in some heroin fueled Consumer Reports product test down at the American Standard offices, you don’t need 500mg Seroquels to get the same clogging action. Ok?
5. Actually, this isn’t true either. 250mg Seroquel has trivial D2 blockade, but Zyprexa 5mg still has some (55%). So 5mg Zyprexa is more likely to treat psychosis than 250mg Seroquel. The equivalences are really to be used the other direction: if you needed 15mg of Zypexa, you will likely need more than 600mg Seroquel…
IF YOU LIKE IT, DIGG IT-- OR REDDIT IT-- OR SEND ME MONEY-- OR RUM--

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===== ====== ===== The Last Psychiatrist: The Most Prescribed Drugs

You may as well find out what you're up to.

Top 20 Psychiatric Prescriptions in 2005
Xanax and Zoloft win. (Zoloft went generic in 2006. Current reduction in cost: zero.)

But, a little perspective:
Most Prescribed Drugs of all classes 2005
Percocet is prescribed 3 times more than Xanax. Lipitor twice as often. Of course, the cost of percocet and Xanax are negligible relative to Lipitor.
Note also that the majority of "most prescribed" are generics. So where does the money go? Take Lipitor, which retails $800/yr for 10mg, $1300/yr for 20mg. Generic lovastatin 20mg costs $450. For that savings, you can slap on a Toprol XL 50mg (branded!) and a metformin, for good measure.

So wait a second, should we force all generics? No. Some don't have generics. So how do you reduce costs? Price caps? Useless. Then what? Not this fake, bureaucratic, pharmacy "formulary" with "negotiated" prices that are really extortion of Pharma by Medicaid and Medicare providers at patients' expense. Socialism isn't working in Venezuela, it isn't going to work here. To really reduce costs, you have to strike where it counts. And you're not going to like it.

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===== ====== ===== The Last Psychiatrist: The Nature Of The Grift

simplified for the purposes of illustration

In The New Yorker, a piece about immigration-- abuse? Cheating?

"Caroline" is a single woman from "central Africa" who, while living in a roach infested NYC apartment ("sometimes they get in my handbag, but they're small") and working in what I assume is a Whole Foods (she thinks "organic" is a scam), she works with a lawyer to complete her application for political asylum. Back home, she was raped and beaten, and would likely be killed if she returns.

The hook of the article is that she made this up in order to gain asylum. She was never raped, never tortured, never etc. The article explains that such embellishment is not only common, but that applicants are often counseled on how to game the system by others (including lawyers) who have been through the process.

But she's a good person, hard working, she just wants a part of the American Dream that is out of reach for native twentysomethings. Is it right to deny her? Oh poorly considered ethical dilemmas, what would the press do without you? The focus of the story--indeed, the climax-- comes when she finally has her appointment wiith the immigration officer: a cold hard-ass (read: white) named Novick in a Matrixy/East German/Kafkaesque interrogation room. Think fluorescent lighting and the hum of alienation.

He wants specifics of her rape and torture, when and where; he wants to know what African hospital she went to and when. She keeps her story tight; she deflects attempts to pin down the medical records. She answers questions about local geography. Novick checks a newspaper to corroborate her story of being in a bombing, but that's where she got the story in the first place.

So: you can read it as this lying bitch is one step ahead of the law, which is harsh, but it's a reading. Or, you can read it as officers like Novick can't always detect lying, they do the best they can. Or you can do what The New Yorker and NPR did, pull the left blinker on the Subaru and suggest it shouldn't have to be this hard for immigrants to come in. They shouldn't have to lie. Also: "Mondale '84"

In the end, the officer found her narrative compelling enough and granted her asylum, and she is a model American citizen by most measures. She has a job, a car and a husband. She goes to church every Sunday. She pays her taxes, and she's never taken a dime from the government.

I'd bet every dime of every person she's never taken a dime from that it scalded the editors like holy water to keep the phrase "goes to church every Sunday" in there, but they probably figured they needed it to appeal to the wingnuts at patriotpost.us and everyone in a landlocked state who obviously hates immigrants, especially ones who aren't from America.

All of those readings provide their respective readers with considerable emotional comfort and reinforce their own moral superiority, which is healthier, I'll warrant, than drinking yourself to sleep in front of (this week) The Conversation; nevertheless, all of those readings would be wrong.

II.

Here's an emotional, exasperated criticism from an immigration lawyer:

[The New Yorker story] encapsulated everything about immigration law that is both dispiriting and outrageous. It is a clarion to new lawyers to keep away from the profession and a motivator to honest lawyers in the field to want to take a long shower after any day associating with his or her peers or "the system."

Can't resist low hanging fruit: "This is what motivates lawyers to take showers?? Is this thing on?"

I get where he's coming from, and I don't blame him for feeling angry about abuses of "the system", but he's not seeing the truth: this isn't an abuse of "the system," this is the intended system. Even though it's illegal, the system wants you to lie.

To begin to see not how this is but why this is, pretend that Caroline had made a left instead of a right and wanted, inexplicably, to immigrate to Greece. She shows up, gets the necessary binder of paperwork, and of course right there on the cover it says they don't want black people either. But she's highly motivated. What's the play? Think about the answer.

The play is: she's got to figure out who to bribe.

The play is: she has to bribe a Greek Novick. And Novickopoulos already expects it.

It is both metaphorically and literally accurate to say it isn't rape or torture, but exactly that system, that she is trying to escape by coming to America.

III.

The system wants Caroline, the system wants there to be a way for "intelligent" and "hard working" and "church going" resourceful people to game the system. All of those words mean "taxpayers." It wants the kind of person who sticks with this tedious bureaucratic process even if it is all a lie; it doesn't want the person who doesn't bother to try to get legal. And, most importantly, when you establish the grift as based on the best "rape narrative", it therefore isn't about the most money. That's what you want to avoid, because Caroline has none of it, and MS13 has lots of it.

What distinguishes this grift from the overt kind-- of Greece, Mexico, Pakistan-- is that in the former case the cheat occurs top down, while in the latter case the cheat occurs bottom up. In Greece, you want a permit? You have to know who to bribe. Bribery may go "all they way to the top," but importantly your bribe has to start from the bottom and move to the top.

In the case of American asylum seeking-- and everything else-- the grift is at the top and it lacks a human face. This story is in The New Yorker, right? So it's hardly news, hardly investigative journalism. So at minimum, everyone in the business knows the score. Novick knows that, in general, much of what he hears is a lie, even if he isn't sure/ignores that he is being lied to right now. Unless you piss him off personally, or flaunt your lying, he doesn't care about the veracity of your claim exactly, just the internal validity of it.

That's the system. The system favors narratives over truth to avoid the terrible reality of reflexive human corruption.

IV.

"Internal validity over objective reality? The system wants you to lie? What madness is this?"

Say you're a gay male asylum seeker. "Back in Brasil they beat me mercilessly, police have gang raped me. I'm told that I can find acceptance in "Southern Carolina." (Shhh, don't tell him. This will be hilarious.)

Your documents are all ready. Your day before the immigration judge comes. How should you dress? Think about this.

(NYT) In the end, Mr. Castro opted for... pink eye shadow, a bright pink V-neck shirt and intermittent outbursts of tears... He had been advised by his immigration lawyer that flaunting it was now his best weapon against deportation.

"Judges and immigration officials are adding a new hurdle in gay asylum cases that an applicant's homosexuality must be socially visible," said Lori Adams, a lawyer

Being gay isn't enough, you have to look gay. But importantly, while no member of the immigration office can deny you for not looking gay:

Rhatigan [from Immigration] said such behavior by immigration officers would not be condoned.   "We don't say that someone is insufficiently gay or homosexual"

"everyone knows" that you have to dress the part. Like your life depends on it.

The system doesn't want truth, it wants internal validity. That sounds bad, but it wants it to be based on the force of a narrative because it doesn't want your life to be determined by the whims of a man with two mortgages or a drug habit or a hard on.

But wait: now pretend you're not gay. Can you... dress the part?

One lawyer recalled a recent client who applied for asylum on the basis of sexual orientation, then showed up a few weeks later with his wife, seeking help with a green card. In 2009, Steven and Helena Mahoney pleaded guilty to charges stemming from a consulting business in which, among other things, they coached straight people on how to file gay asylum claims.

Is it lying? Yes. Is it a grift? Yes. But is the fake-gay married guy more likely to rape a bus of schoolkids or file quarterly 1099s?   That's the system.

V.

The unanswered question is: how? How can a system operate on words alone? "All you have to do is say you were raped and you're in?" No, of course not, you have to provide proof.    I can't just roll up to the Apple store and say I have $100, I need some sort of proof that I have $100. Someone has to take my words--- maybe even lies-- and translate them to tangible proof. So maybe it's the bank, or maybe it's Visa who takes my "lie" that I have $100, and makes it real for the merchant by forcing me to pay $15 a month until that lie becomes true.

Caroline is fabricating a rape narrative. Novick wants proof. How does she prove it? What is the mechanism by which the American system converts words-- truths or lies, either way-- into physical evidence? What does the system give her-- indeed, demand of her-- as a means of manufacturing the necessary proof of her rape?

To buttress her asylum claim... she had been attending group and individual psychotherapy sessions, as part of a program for survivors of torture.... She has individual sessions with a psychiatrist, who prescribes antidepressants: Zoloft, Wellbutrin, trazodone.... "I throw it away."

Note that she didn't really have any symptoms; the system required her to go as evidence that she was raped. i.e. psychiatry is not the unintended collateral damage of a terrible system, it is the necessary part of the dialectical workings of (American) society, it is the specific way in which theory/lies/abstractions are physically manifested.

By "required" I don't mean codified. There's no rule that says she has to see a shrink. But she still has to. It will look weird if she goes before the judge without a PTSD diagnosis. Nor does a person actually need to go to a psychiatrist, but they must at minimum employ the language of psychiatry: traumatic, depressed, flashbacks...

I do not use the requirement of psychiatry lightly. I mean exactly what I say: psychiatry makes words manifest into tangible reality.

Remember Castro who was not gay unless he appeared gay-- the reality was irrelevant, what mattered was the narrative? Even he was in it:

He shared a letter from his psychiatrist confirming that he took antidepressants for the post-traumatic stress disorder caused by his abuse.

How much did it cost the system to help Caroline game it? 2 therapy visits/month at $60/visit + 1 "med check"/month @ $50/visit + medications @ $150/month (assuming generics) = $320/month. However, and this is the point, it made a profit on its investment, not just in taxes but in "blast radius:" she'll be a positive influence on others, her kids, who will grow up educated, employable, etc. This is the same force that gives you $700/month in SSI because that is just enough to prevent you from robbing a Dunkin Donuts or chasing a dragon, not to mention way cheaper than incarcerating you or turning the Bronx back into a police state.

The system wants Caroline because she's good for the system. Of course, she is black, but at least she's African black; and, anyway, you can't have everything.

VI.

No doubt all this talk about "the system" seems too abstract to be real, almost at the level of conspiracy theory, so let me offer you an everyday example.

Say you get a bill from Verizon or Blue Cross and you're like, wtf? Is this in base 6? So you call a number that begins with 800, put it on speaker and surf the internet for the next hour to the background music of genocide.

Finally, Sally comes on, and you know she's going to want to help. Here's what I do every single time. When Sally says, "Verizon's Blue Cross, I'm Sally, how may I help you?" the very first thing I say is, "Hi, Sally. I'd like to speak to a supervisor."

Because at the level of a Sally, nothing I can say to her to get her to do what I want exerts nearly as much pressure as "the system" exerts on her to get her to NOT do what I want. It's not just that she doesn't have any power, it is that even though she has power, the exertion of that power in my favor results in negative consequences for her. Is she going to get promoted if she makes me happy?

My only recourse is to go high enough in the system such that my pressure is greater than the pressure from the top; where giving me what I want doesn't matter to that level. Where helping me benefits that person, not hurts them. Sometimes that's pretty high up, sometimes it's only one more level up, but it is rarely at the ground floor. So I always bypass it.   In small letters on the back of your Verizon bill, it says very clearly, "Rookies and rubes, please call 1-800..."

But if I was in Hungary, this is the last thing I want. In Hungary, the move is to work Sally and keep her supervisors out of it, because Sally is cheaper to bribe than her supervisors.

Another example. In The Sopranos, Burt and Patsy try to shakedown a local Starbucks; apparently they either believe they're in Hungary or that it's 1971. So they tell the manager about the possibility of tornadoes and smallpox unless he pays up, but the manager who lives in America just looks at them incredulously and invokes the impassable authority of the American system. "Dude," he says, and I'm paraphrasing, "every dime is accounted for by the computer." Not by CEO Howard Schultz; the computer. It's unassailable because there is no such thing. The computer is "the system," the computer is the spirit of America. "You can detonate a nuke in here," he continues," Corporate doesn't care about me. They'll just re-open another one the next day." That's the system. You may say it's dehumanizing corporate greed, and it is, but on the other hand the system has (for example) protected the manager from this kind of nonsense and no cops were needed.

Rail against it if you want, but unless you learn to operate within it, then Patsy will have been right: "It's over for the little guy."

VII.

A final example.

You're in college, and between the alcohol and the orgasms you're not doing well in your classes. Maybe in danger of failing out. You need to convince the Dean to let you redo the tests, redo the papers, anything-- just not kick you out.

You're at the computer. You have his email address.

What are you going to write? What is the only thing you can write?

VIII.

The reflexive counterargument is that this system is immoral. It allows cheating; it supports the primacy of narratives over reality; it shouldn't be like this.

But the system doesn't make moral judgments, it saves those for TV, all of the calculations are economic, evolutionary. The system isn't immoral, it is amoral. The fundamental problem is that people are easily corruptible. You'll never be able to close all loopholes, so you have to decide which ones are the worst.

Am I saying Novick knows he's being lied to, and knows that he's supposed to let her in anyway? That the judges know that we need more hard working Africans? Of course not. Yet Caroline got in anyway.

No person or group of people set this up, it developed, logically, through the push-pull of individual wants and needs in diverse and seemingly unrelated areas. Add up all the vector forces in four dimensions, this is what you get. A big vector is bribery and personal corruption; another vector is the size of the medical field and the incomes it creates (including SSI); another vector wants (hispanic) immigrants in jail because there's profit in it; another is institutionalized narcissism, where everyone (including judges and psychiatrists) knows what you say about yourself matters more than what you are... and etc.

"Not everyone cheats!"

I know. None of this is to minimize the real difficulties asylum seekers have. Only 30% of the asylum cases are approved. The point here isn't how to get asylum; the point here is about the nature of the grift. Asylum seeking is merely one example of the same grift that is operational in SSI, in criminal justice, in getting a mortgage. How does the American system "fail" at the margins-- allow itself to be gamed? It fails in specific ways and not in other ways; bribery, for example, isn't rampant. Neither is kidnapping or trading sex. Before you say Caroline shouldn't be able to cheat, ask why does the American system favor this kind of cheating?

Don't make a moral judgment, don't ask if it's "right," just sum the vector forces.

Consider also the consequences. If narratives are valued more than reality, or at least serve as proxies for reality, then right or wrong, what happens when that narrative is challenged? What happens when society changes course and says, "I don't believe all these asylum seekers were tortured, I want physical non-psychiatric proof." Or: "I don't believe you all are disabled, I think you should all be working at McDonalds." Or: "I don't think you all have any chance of paying this mortgage back, you should be living in an apartments."

What happens is the same thing that happens at the individual level: rage. Now you have to sum some vectors to decide whether paying them $700 a month or letting them become Americans is better than the alternative.

The immediate problem is that the grifts all rely on one key element: money. The system can allow itself to be cheated if there's money to support it, just like a grocer can toss you a free apple as long as the margins are still good, because ultimately it's good for the business and hence for the system. But when that money dries up, the institutional grift has to be closed but it will by necessity open elsewhere. Down the chain. From institutional to individual. Now instead of Novick being a cog in what looks like a giant carny act based on words, Novick himself starts demanding a little payout. Uh oh, now all your lies and diagnoses and credit cards don't matter a lick because Novick just Red pilled everything-- he wants cash. Now the system is wrecked, because the system's inherent cheats fulfilled a larger purpose; Novick has obliterated the purpose. So the Carolines don't stand a chance; bribery is the new grift, and no one trusts anyone. Now you have Greece. You can do what they do, choose your prime minister by heredity and placate the people with long vacations and low retirement ages, until the day you can't. And then they'll thank you for two generations of free lunches by rioting.

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===== ====== ===== The Last Psychiatrist: The Near Death Of A Salesman
The barbarians are coming.

He was in really good shape, except for the belly. At home he could eat right, exercise, go to church, raise two sons and a daughter, but three out of seven days he was in a car or in a hotel. Real life was on hold. So the cheesesteaks, the corn chips, and the sodas belonged to a different reality, and when the doctor asked, "do you have a good diet?" he answered yes and he wasn't lying.

He didn't take any medications, the only thing he took was Lipitor and a blood pressure pill, that's it. He had some Percocets for his back pain from a fall nine years ago, he got Xanax off the internet, he took one or two of those a day, but it was just to help him relax when he was traveling, he didn't really have a disorder so it didn't count. Also Ambien.   He also had some Plavic or Plavix or something, but he didn't really need it, he only took it because his doctor didn't want him to get any more clots, but he hadn't had any clots for three years. So.

Really, in real life, if he didn't have to work or travel, he wouldn't really need any of this stuff. And this wasn't his real life, anyway, he was still planning his real life. He was 47-- three years of youth left. Three years to get his real life started. Three years before he had to get depressed.

Drinking was part of that other reality, too. He had a couple of drinks at business lunches, one or two before dinner, then some wine, a few more before bed; and yes, ok, he drank when he was at home too, a bottle of wine with dinner and a few vodkas with Letterman, but he was never sloppy, always in control. He was sure his 12 year old son didn't know. When the doc asked, "how much do you drink?" he truthfully responded wine with dinner. The rest was not planned, he never thought, "I got to get some martinis into me." So it didn't count.

For twenty years, none of it counted.

And there were the women. When he first met his then hot wife at a sales meeting, 20 years ago, they were young, making money, and sexually hungry. They drank, they smoked, they were naked in hot tubs. But after they had kids she "became" a prude; "became", in quotes, because he didn't actually remember the transformation; he just saw what she appeared to be, now. The rest wasn't past, it was an alternate reality. He hadn't forgotten that she had once tied for first in a bikini contest-- and what happened after; it was just a different reality.

So yes, years on the road he had had some one night stands. Come on. They didn't count, they were not planned, he never thought, "I got to get some" and etc and etc.

Besides, the women he slept with were not as attractive as his wife. But they looked at him like they knew he could dominate them, and that was enough.

II.

It wasn't that he didn't love his wife, or something.

His wife was a lot like him. She was in sales and she could drink a good game, too. But she had a more stable view of diet and so while he had the belly, she was still built. But her face was gaunt: there comes a time in a woman's life when she has to choose between her butt and her face. She chose. Anyway, men didn't notice the faces of the women they wanted to sleep with, and certainly not the faces of the women they didn't want to sleep with.

She never flirted, but it didn't matter. The only salesman who wasn't trying to get her face down in Courtyard Marriott was her husband; the irony was that if he knew what other men wanted to do to her, it would have made him violently jealous and constantly erect.

But he didn't know-tice, because his wife wasn't real. He didn't see his wife as a person with a past. Or a future. She was just part of his ongoing present.

Though he wasn't particularly interested in having sex with his wife, he was very interested in imagining sex with this wife. His default masturbation fantasy was thoughts of his wife (20 years ago) in all sorts of sex with all sorts of people. He didn't really want it to happen-- and he knew she would never, ever actually cheat on him-- but he couldn't help imagining it. He tried to fantasize about other women, why not? but it always came back that adulterous slut in a bikini, or in white heels, or both. His favorite fantasy was that they'd be on their honeymoon in Bermuda, he'd get drunk and pass out, and the couple they'd been having dinner with would take her out by the pool and work her over from both ends.

III.

His son's homework was: give four examples of why FDR was a great President. His son had started a paragraph on how FDR got the country out of the Depression.   But he knew that a lot of the things FDR had done had actually prolonged the Depression. He tried to explain to his son that news, and even schoolteachers, sometimes had a "liberal bias" but it was hard to explain what "liberal" meant to a 12 year old. And now he couldn't remember the specific mistakes Rush had said FDR made, so he tried to intuit what John Kerry might have done. "He raised taxes on the rich, but that meant they didn't have money to build factories and railroads, so everyone ended up being poorer."

He fantasized about having his own radio show. He'd be perfect for afternoon drive. He could do a Monday segment where he'd round up news from Asia and talk about how they were taking American jobs; and on Fridays he could lighter segment called "Hollywood's Hoes" on how it destroying traditional family values.

"Didn't FDR defeat the Nazis?" the boy asked.

"No, actually, he almost lost to the Nazis. He didn't want to use the bomb because he was against nuclear war, see? He kept wanting to go through the UN, which at that time was called the League of Extraordinary Nations.. Meanwhile, the Germans got away with the Holocaust.   It was only after FDR died that Truman-- or Eisenhower, I can't remember-- did what had to be done." He could also draw, and if he could just get some free time he could definitely do political cartoons. He imagined drawing Berlin and all the people running around in a panic-- "Evakuate! Evakuate! Roosevelt bin kaput!"

What would be better than a political cartoon would be to recreate that in a sketch, like for SNL. That would be hilarious. He'd play a worried Hitler who schemes to steal FDR's body to resurrect him. Why not? He could act, he had great timing, he was pretty good looking, yeah he had the belly but if SNL tapped him he'd go hardcore to the gym so that wouldn't even be an issue.

If he could just get some free time, he could write them a pitch.

IV.

And then he had a stroke.

That's what his wife called it, but could he be driving across Oklahoma if he had had a stroke? His balance was off, and his right arm was definitely weaker, but he wasn't slurring his words (only a little) and he wasn't paralyzed.

His wife had noticed these things that morning and tried to take him to the ER, but he said NO WAY.   Finally she forced him to phone his doctor, who quickly set them both straight: "you do realize this is the fifth time this month you've had some odd physical problem?" They played golf at the same course. "You're somaticizing. Take a Xanax. Stop drinking."

She pestered him, this was "serious", not to be "ignored." Yet she had a detached tone, she was talking towards him, not to him. How serious could it be if she wasn't really worried? He didn't know that after twenty years of marriage it's easy to misinterpret not caring as not worrying.

But it was odd how he wrote his name with small, scratchy movements; how he couldn't grip a fork the right way. How he raised his arm tentatively and unnaturally as if his shoulder socket hurt badly, though it didn't hurt at all. How it felt like it wasn't his arm at all.

He had a friend who was a doctor, one he could level with, one who'd be straight with him. He'd call him, get some real answers.

Well, he wasn't actually a doctor, he was a psychiatrist, but so what? He'd know a stroke, right? He knew him from college, no, he knew his wife from college. No, wait: his wife knew his wife from college. He had never actually met the psychiatrist. But so what? The wives were close.

He left a message, the psychiatrist called him back.   "Look, I don't want to waste your time, but my wife has been nagging me, you know how that can be..." He explained his symptoms, and was very careful not to leave out any of the psychological aspects, the stress, yes, even the drinking, he wanted the psychiatrist to understand the complete picture, the complete man, so he could give a reasoned assessment, and if the psychiatrist thought he was nuts, well, all right then. He told even told him he had slept with a stripper in Kansas... could this be a guilt reaction? He just wanted the shrink's honest opinion, man to man.

"Ummm," said the psychiatrist, "I'm pretty sure you're having a stroke."

V.

He sat down. Of course it was a stroke. He had known it all along, but he hadn't wanted to admit it.

A stroke. Oh my God, now what? He hadn't died, but he knew the weakness would be permanent, and every moment he didn't get treatment was risk of more weakness, more infirmity.

All those things he had dreamed about, all the things he had wanted to to-- a radio show, golf pro, the novel, losing weight, going back to school to become a lawyer-- all those things would never happen.

He wouldn't be able to finally read The Federalist Papers with his son, wouldn't be able to learn trigonometry to help him with his homework; he wouldn't be able to wake up at 5am every day with his eldest son and help him train.

The stroke had taken all that away from him. All he'd be able to do now as live day to day.

VI.

That evening, too drunk to work on a cartoon, he stumbled into his daughter's room, sat on the bed. It crunched, he pulled back the sheets, there lay a spiral notebook. Poems, song lyrics, quotations. Kids still did that? He wondered why. He used to do it, too, because his parents were too self-absorbed to notice him in any meaningful way, and no one else would listen. He remembered his block capital letters: THERE IS NO PAIN YOU ARE RECEDING/OUT OF THE CORNER OF MY EYE.

On one page was a song even he recognized as being by T-Pain, or one of those guys, and next to it another song he thought he might have seen performed on Letterman, or maybe it was a poem, and she had written out all the lyrics. His eye caught two stanzas:

Why isn't anything happening in the senate?
Why do the senators sit there without legislating?

Because the barbarians are coming today.
What laws can the senators make now?
Once the barbarians are here, they'll do the legislating.

VII.

Three weeks later he went in for an MRI. Nothing. Ha. The psychiatrist was wrong, what did he expect from a psychiatrist. No stroke, it was stress after all.

Now there was no reason he couldn't do all those things he had wanted to do.

He suddenly felt restless, confused; his face became serious with thought. Night had fallen, and he was still alive, still healthy. What was going to happen to him now?

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===== ====== ===== The Last Psychiatrist: The Neurobiology of Wisdom
It's always in the last place you look.

Dr. Henry Nasrallah asks Does psychiatric practice make us wise?

We also integrate our complex observations and findings with the rich collage of each patient's unique cultural, religious, and educational background. We strive to find hidden or higher meaning in patients' symptoms... We assess their potential lethality toward themselves or others and examine the often tortuous course of their existence. And, unlike other physicians, we observe their transference toward us and simultaneously examine our own countertransference

etc. What can be said?    The article is self-aggrandizing wishful thinking, the kind of thing you expect from a bass player when he tries to convince a girl that he's the soul of the band.

The article could be ignored, if it didn't take a tragic turn off a uranium mineshaft in the final third.

The wonder of psychiatric practice is that we somehow navigate each patient's unique jungle of thoughts, emotions, behaviors... By doing so, we develop different regions or circuits in our brains than surgeons, radiologists, or internists do. Meeks and Jeste's wonderful article about the neurobiology of wisdom suggests that psychiatrists' brains probably develop "wisdom circuitry" via advanced neuroplastic connectivity in the:
prefrontal cortex (for emotional regulation, decision-making, and value relativism)
lateral prefrontal cortex (to facilitate calculated reason-based decision-making)
medial prefrontal cortex (for emotional valence and prosocial attitudes and behavior)

I hope that readers of this blog can now see through this inanity. This is no longer just wishful thinking; it's an outright lie. I don't need to read Meeks and Jeste's "wonderful" article to know that there is absolutely no way they could show that psychiatrists develop wisdom circuitry of any kind, let alone through the three made up pathways (aren't they all just the prefrontal cortex?) he lists in bullet points ("I've summarized the points you need to know for the test with bullets.")

Nevertheless, there's Nasrallah's article. You don't realize how significant it is: it becomes another article listed in the superscript of references no one looks up, supporting statements like "there is considerable evidence that..."

II.

It's not all Nasrallah's fault: he saw porn and couldn't look away. The Meeks and Jeste article he references has a catchy title-- The Neurobiology of Wisdom-- and it's in the Archives of General Psychiatry. But Meeks and Jeste's article isn't just bad, it is horrendous. It's the research equivalent of a sarin gas attack. Everybody dies, nobody can tell why.

It would be impossible to list all of the specific problems with the paper. As proxy, here's the quote at the beginning of the article:

Of all the pursuits open to men, the search for wisdom is most perfect, more sublime, more profitable, and more full of joy.--Thomas Aquinas

That the six letters w,i,s,d,o, and m appear in that order is the only similarity between the "wisdom" sought by Aquinas and the one pursued in this article. While this might seem like an academic or minor quibble, it's not: the purpose of the paper is to conflate "wisdom" with a set of characteristics that have nothing to do with wisdom at all, and claim a biological link. The article studies the color red and finds there "the essence of NASCAR."

The pursuit of wisdom for Aquinas was the pursuit of ultimate truth or cause; the article uses the term as a relativistic judgment on behavior. Here are the six components:

(1) prosocial attitudes/behaviors,
(2) social decision making/pragmatic knowledge of life
(3) emotional homeostasis
(4) reflection/self-understanding
(5) value relativism/tolerance
(6) acknowledgment of and dealing effectively with uncertainty/ambiguity.

Don't fall into the trap: though these may be positive attributes, only (4) has anything to do with wisdom as defined by Aquinas, or even as described by one of the references they use, e.g:

reasoning ability
sagacity
learning from ideas/environment
judgment
good use of information
insight

Spend a moment and think about the difference between the two "wisdoms." But don't spend too long: the article takes the first group, finds a poor proxy for each, muddled by fashion and politics, and reviews the neurobiological data for those.

III.

Here's the first one:

One of the most consistent subcomponents of wisdom, from both ancient and modern literature, is the promotion of common good and rising above self-interests, ie, exhibiting prosocial attitudes and behaviors...
"Common good rising above self-interests" would make Ayn Rand stab a harp seal; but regardless of what you think of Rand, it's at least evident that this isn't at all "consistent" in the definition of wisdom. Or are there no wise capitalists? But accept it and follow the logic to your doom:

...such as empathy, social cooperation, and altruism.6 Thus, sociopaths, who may exhibit exquisite social cognition and emotional regulation that actually facilitate their selfish motives, would not be considered wise.
So selfish is not wise. Ok, I get it.

Altruism: Altruism overlaps with cooperation, although altruism is notable for the potential harm or "decreased fitness" the altruistic person risks to help others.55 Harbaugh and colleagues56 demonstrated that the idea of voluntarily giving money compared with that of paying taxes... caused increased activation in reward circuitry... Similarly, Moll et al57 reported that both receiving monetary rewards and deciding to donate money activated ventral and dorsal striatum. This somewhat paradoxically suggests that the neural substrate of altruism may be akin to that of more instinctual self-pleasures.
I defy anyone to tell me how that paragraph describes altruism as putting the common good above self interest. If altruism makes you feel good, then it doesn't rise above self-interest. I'm not saying altruism isn't valuable, only that if it is valuable because it rises above "selfish motives" selfless, then the research suggests it isn't valuable (modus tollens).

IV.

In order to illustrate what this paper did, I'll explain it backwards: regions in the brain typically thought of as "reward centers" were seen activated in studies of donating money; the giving of money is thus labeled altruism, which, being a selfless activity, is "prosocial," which, of course, is a component of wisdom.

Hence, one can write the following sentence: "There is evidence showing a neurobiological basis of wisdom."

V.

The entire article is like this. One more example:

Value Relativism/Tolerance: Tolerance of other persons' or cultures' value systems is often considered an important subcomponent of wisdom.
Oh my God I need a nap. Is this really true? I'm not asking if desirable, I'm saying is Julius Ceasar not wise?   Odysseus? Any of the Indian killing Founding Fathers? Or are they wise except for their wanting to take things over?

Brain Localization via Neuroimaging. Neuroimaging studies of tolerance have frequently focused on prominent societal prejudices, especially those related to race/ethnicity. Some investigations have demonstrated that the regulation of "automatic" prejudicial responses follows a neurobiological pattern similar to that described for impulse control: dorsal ACC detects an undesirable attitude surfacing, prompting lateral PFC inhibition of undesirable attitudes, and leading to downstream amygdala deactivation.122-123

First of all, the paragraph tells you these studies are about automatic race bias, e.g. does the picture of a black face make you think of the gun or the hammer? But what does that have to do with "tolerance of value systems?" Nothing, as they admit in the next paragraph:

While sharing rudimentary neurobiology with impulse control, value relativism is conceptually more complex and its study would benefit from the development of novel measures/tasks.

Here's the point: since you admit that paragraph doesn't support your argument, why do you even write it down? Because then you can say:

Summary. Dorsal ACC and lateral PFC play important roles in tolerance of varied value systems by detecting and inhibiting, respectively, expressions of prejudicial responses.

VI.

One might now ask, "why was this paper even written, let alone accepted for publication?" Go back to the quote:

Of all the pursuits open to men, the search for wisdom is most perfect, more sublime, more profitable, and more full of joy.--Thomas Aquinas

Note that they dropped the "Saint." Meanwhile, there's no problem referring, a few sentences later, to Gandhi as "Mahatma." That's okay, because no educated person actually thinks Gandhi is a saint, but there are still plenty of numbskulls who need to be reminded that Aquinas isn't.

Cultural narcissism; the prevalence in science of "end of history" guys who think this time is different from all others, everyone who came before was stupid, naive, myopic, or less ethical. The authors may even be good Catholics, who knows, but they know philosophy was just marking time until the invention of the MRI. Summa Contra Gentiles becomes, well, a footnote.

They don't realize that their belief in the "neurobiology of wisdom" is nothing more than faith, structurally no different from Catholicism: a hierarchy of beliefs with no foundation in physical reality, and an endless stream of words.

But Catholicism doesn't call itself a science; and Aquinas at least had logic on his side.

-------

update

Previous post on the overreach of neuroradiology

----------------------------
Summa contra gentiles, from where the quote was taken, was Aquinas's discussing "wisdom" using arguments of reason, not religion:

Some of the Gentiles, such as the Mohammedans and the pagans, do not agree with us on the authority of any Scripture by means of which they could be won over--in the way that we can argue with Jews by appealing to the Old Testament and with heretics by appealing to the New Testament. But they accept neither the Old nor the New Testament. Therefore, it is necessary to revert to natural reason, to which all are compelled to assent

--------------

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===== ====== ===== The Last Psychiatrist: The New Yorker Writes About Power

With authority.

I've been a subscriber for almost thirty years, and I'm always hopeful it won't again contain another Updike story or Hendrick Hertzberg screed, but inevitably disappointed am I. I guess it's hard to find different writers for a magazine that purports to be for the literate when it is really a middlebrow primer for an unsophisticated political bias.   If that bias catered to the liberal or leftward leaning affluent it would be at least worth the price of subscription, but it promotes a more general bias: power is bad. Anything the powerful does is wrong.

To illustrate this, consider the latest issue containing an article, "Power Hour." It describes an impromptu experiment on the world's powerful (i.e. Paul Wolfowitz) that unfortunately failed to show the intended result, namely, that he's a jerk.

The fact that the experiment failed didn't stop The New Yorker from trying to portray Wolfowitz as a jerk anyway, even though his performance theoretically showed that he was not a jerk, by the outcome measure of the study. They even commissioned a caricature of Wolfowitz to accompany the article, because, well, he's a jerk, of course. No matter what science says.

My own unscientific study suggests The New Yorker's readership is especially those who believe that the little guy always gets trampled on by the powerful, but that they, the readers, are neither little nor powerful, they're in the middle. They are a select group that lacks power, but possesses wisdom. They understand what's really going on. Coincidentally, this describes another overlapping group: academics.

II.

This coincidence makes the second sentence of the article "Power Hour" so perfect:

To academics, one of the best [inverse] indicators of a person's place in a hierarchy is his tendency toward "perspective taking"--"stepping outside of one's own experience and imagining the emotions, perceptions, and motivations of another individual..." An assistant is perspective taking when he gets the boss's coffee before he asks for it; when the boss forgets to pay the assistant back the $3.75, he is not.

The distinction may seem like the main point, but there's a subtext: the boss is a jerk in both examples. I'm willing to bet real money that if you had to guess who reads The New Yorker, it would be the assistant.

III.

All of this is besides the point. The point is how an amateur researcher redid an experiment published in 2006 in Psychological Science about the effects of being powerful, this time using attendees at Time's 100 Most Influential People banquet. I'll describe the experiment in detail, but let me preface this with the observation that it seems not to have occurred to the researcher, nor anyone at The New Yorker, that "Most Influential" might be a different group than "Most Powerful."

Here's the experiment: take powerful and not powerful people, and have them draw an E on their foreheads. Powerful people, as it suggests above, have no interest in "perspective taking" and so will write it facing themselves, because they are self-oriented; not-powerful people will write it facing out (legible to observers) because they will be better able to assume another's perspective.

If this sounds like crap to you, you're right.

But it gets worse.

The New Yorker writes:

The hypothesis of the Psychological Science study was that the more power a person has, the less capacity he has to take another person's perspective.

Which is exactly not what the hypothesis of the article in Psychological Science was. The actual hypothesis was:

we hypothesized that power would decrease perspective taking.

That gerund is extremely important. The actual hypothesis doesn't claim less capacity, or less desire-- simply that it happens less. It could happen out of lack of capacity, but also maybe because of lack of time, need to distance oneself from the cacophony of a myriad of individual perspectives, a blaring iPod, solar flares, alcoholism, etc. How a powerful person writes an E tells you absolutely nothing about why he did it that way, if indeed it is even true that there is an association between being powerful and drawing an E. But The New Yorker wants it, wants it very badly, to be about a defect in ability.

In fairness to The New Yorker, the authors of the study themselves make this same mistake.

IV.

Start from the middle-- study design. The subjects were not actually powerful: they were college students, age about 20. They were primed for power by being asked to write an essay about

either an experience where they had power over someone (high power group), or
an experience where someone else had power over them (low power group)

You can see that simply the ability to recollect such an experience is a huge confounding variable.   Imagine an actually powerful person trying to recall being powerless-- is this person now primed for powerlessness, or-- rage? Which is entirely different than the priming a powerless person asked to recollect being powerless might experience (e.g. shame.)

It seems to me that a better priming method-- if you're going to do it at all-- would simply be to have them pretend to be powerful or not; a king, or a slave.

It's also worth noting that 70% of the college student subjects were women. Discuss.

V.

Next comes the drawing of the E. You should probably sit down for this:

We used a procedure created by Hass (1984) in which participants are asked to draw an E on their foreheads. One way to complete the task is to draw an E as though one is reading it oneself, which leads to a backward and illegible E from the perspective of another person. The other way to approach the task is to draw the E as though another person is reading it, which leads to production of an E that is backward to oneself. We predicted that participants in the high-power condition, compared with those in the low-power condition, would be more likely to draw the E in the self-oriented direction, indicating a lesser tendency to spontaneously adopt another person's perspective.

Jean-Luc Picard on the left would be, therefore, in the high power condition, and Hendrick Hertzberg on the right would be low power.

Which is fine, except: why does the direction of an E have anything to do with being self-oriented?   You'll observe Picard is left handed, and Hertzberg is right handed. Think about that. Are there other reasons to think this E reflects self orientation and not, for example, the ability to write backwards ("power-primed are more dexterous?" "Power primed people draw horizontal lines from left to right?" ) or any of a billion other possibilities? In other words, just because the group is called "high power," doesn't mean it has anything at all to do with power.

So while the results of the study were that the "high power group" was three times more likely to draw the E backwards, is there any conceivable way we can infer that actually powerful people do it, or that this has to do with power at all, or self-orientation? The New Yorker cleverly adds a distraction:

(Or: B = -1.51, SE = 0.76, prep = .88.)

Unexplained, just sitting there, as if to say, "oh, look, we don't understand all that nerdy stuff, just accept that science says it's true."

But is there any validity to it at all? No. and not just because it's ludicrous.

The authors cite Hass as the originator of the method, and as evidence for the validity of the method. Hass believed that people who were self-focused looked at themselves by occupying an external perspective, looking back. Read that again. In other words, a legible to the external observer E meant you were more self focused, not less. It doesn't measure the ability to adopt someone else's perspective: it measures your ability to see yourself.

So let's review: Hass has a theory that is entirely untestable, it is then used backwards in Psychological Science to draw conclusions about something different, and then applied wrongly for The New Yorker. Awesome. Science is relative anyway, and the real point is Wolfowitz is still a jerk, right?

VI.

But let's look not at the protocol, not even at the premises, but at the meaning of the words. Since the power level is hardly quantifiable, could the study be about something else-- that would make more sense of the results?

...recent views that power can lead to objectification, the tendency to view other people only in terms of qualities that serve one's personal goals and interests, while failing to consider those features of others that define their humanity... [making] it easier for a power holder to use them as tools in the service of his or her goals...

I don't know about power; but it is definitionally narcissism. Replace the word "power" with narcissist and it becomes clear:

the high-power individual's self-concept remains more rigid; individuals with more power in their marriages resist the identities imposed on them by their less powerful spouses, and when relationship partners become more emotionally similar, it is the lower-power partner who has done the majority of the adapting...

The powerful, on the one hand, are less accurate than the powerless in estimating the interests and positions of other people and are more likely to make self-serving attributions. People with more power form less complex interpersonal impressions than people without power, basing their impressions of others on expectancies and stereotypes.

The problem is the conflation of power with narcissism. Not all-- not even the majority-- of narcissists are powerful. And not all powerful people are narcissists.

You might think I'm splitting hairs, but the authors themselves define power differently than they actually use it:

Power is often defined as the capacity to influence other people; it emerges from control over valuable resources and the ability to administer rewards and punishments.
Oh well.

VII.

It should be obvious that Hass's version is just as empty and meaningless as the Psychological Science version.   Hass's study is an experiment testing a hypothesis based on articles of faith, a slightly distorted version of the famous logical fallacy:

witches float
Lisa is a witch

therefore, Lisa should float.

Never mind that Lisa is really Arthur and he knows how to swim. The authors of the Psychological Science study believe it, so let's grant them their premises are indeed facts. But they then go on to devise an experiment that actually tests the opposite of the (preposterous) hypothesis.

Published science this bad rarely happens by accident, it requires planning and execution and is thus inevitably associated with having an agenda. A quick look at the authors' bios reveals the agenda: power corrupts absolutely, and absolute power is worse.

VIII.

But back to Wolfowitz. Let's predict the outcome. He's probably self-focused? So according to Hass, he should draw the E legible to observers. But according to Psychological Science, powerful Wolfowitz should write the E backwards to outside observers, because he doesn't take other's perspectives. (Either way, it proves he's a jerk.)

Before I tell you what he did, I'll give you The New Yorker's explanation of the results, which includes the words "bar," "alone," "deposed," "shaky," and "hesitant"-- all in the same sentence; followed by a completely made up explanation that allows you to be right even when you're wrong:

He apparently was not demonstrating the "carryover effect," by which a person who has been stripped of influence continues to behave as if he were still in power.
Thank God for science.

The pretense of The New Yorker is that they, by virtue of not being powerful, must be smarter than Wolfowitz, who is a priori an idiot.

Well, is it possible that Wolfowitz sees a set up? Maybe he's more clever than you credit him?

Wolfowitz drew his E lowercase.

IX.

It seemed odd that, in a room full of powerful people, no one was acting the way powerful people are supposed to.
Oh, I don't know, given that there are so many things wrong with that sentence alone, it's not so odd.

[One of the authors of the PS paper] attributed the anomalously unpowerful results of the Time 100 trial to the use of blue Post-its [stuck to their foreheads, on which they drew the E]. "Blue creates a negative set of emotions, and when people are experiencing these emotions they think more deliberately," he said. "If you had used red, it would have gotten at their more spontaneous inclinations."

Got that? But Wolfowitz is still a jerk, right?

===== ====== ===== The Last Psychiatrist: The New York Yankees: Mission Accomplished

The House that George built.

Sure, now that the Yankees are in the World Series I want them to succeed, I'm a New Yorker after all, and I certainly don't want to see them lose, humiliated, or suffer injuries. But in all honesty, we have no right to be there. We have no business going to the Series-- we got there on a series of false pretenses and bullying, facilitated by an impotent League that allowed us to get away with all kinds of manipulations and distortions. The reality is that Georgey has turned the Yankees into a rogue team. He's squandered the respect and goodwill of the fans all in pursuit of his own agenda of dominance.

I hate to say this, but we simply don't deserve to win.

The Yankees have made some serious mistakes in the League, and they've never taken any responsibility for them. Yankees fans ignore the mistakes, forgive the missteps, and turn a blind eye to everything, simply because it's their team. They conveniently forget the 80s, the steroids, the domestic violence, the racism. They're nothing but fans.

The reporters are equally to blame, they have completely given up on objectivity. Ever since they were allowed to travel with the players and enter their lockerrooms, they've become extensions of the teams. They seem objective, but all they care about is maintaining their privileged access to the players, and if that means doing a fluff piece on A-Rod boning Kate Hudson instead of looking into Congressional perjury charges, well... It's sickening, we should be ashamed, but we're not. And they call Erin Andrews a reporter? She gives new meaning to the word embedded. They use her breasts to hide the fact that she's just a cheerleader which I realize doesn't make any sense, but that's what's stuck in my head. You know?

No one seems at all concerned that the guys who call the games are all former players and coaches. No one calls them out on the obvious conflict of interests. You read about a game or listen to it on the radio, you think you're getting objective information, but how do you know? "Strike 3!" Really?

No one seems surprised that the national newspaper of record is called the New York Times. Hello? Is anybody getting this? I'm sure the Houston Chronicle has a different perspective, but we deliberately suppress other viewpoints. I challenge you to even find a copy of the Houston Chronicle anywhere in the city.   Try and write a story about how power is being transferred from Steinbrenner to his sons, and see if you're ever allowed in a ballpark again. So much for discourse. So much for dissent.

Most Yankees fans are completely blind to the fact that the rest of the world hates us.

If nothing else, the Yankees have been guilty of arrogance. What makes us so great? That we have more money to spend on their team? We may have a superior record, but that has to be looked at in the context of our ability to spend more money. The Yankees can just buy whatever talent they need. And Yankees aren't smarter or more sophisticated than other players, they just have better equipment, better facilities. How the hell are the Mariners going to compete? It rains there constantly. The Yankees are just steroid fueled schoolyard bullies. The Yankees are the United States of baseball.

Funny how while we're busy destroying every other team, we ignore the fact that our players all come from those other teams. It's not like we have any native talent, we're a ballclub of immigrants. But you won't hear that on ESPN.

Let's not forget a fundamental truth: yes, we're New Yorkers and we love the Yankees, but that's an accident of history. If we had been born elsewhere-- if we were born in Houston, we'd be Astros fans, and every time a Yankee got pulled over for a DUI or got their head taken off by an errant fastball we'd ejaculate in our pants.

If we want to be respected throughout the world, not just feared, we have to come together, come to understand that we're not just Yankees, but baseball fans, and we have to respect that unity above all.

Look, what happened in 2001 obviously was a tragedy. Of course I'm not saying I'm happy Arizona decimated us 4 games to 3, I'm not saying I want it to happen again, I'm not saying we deserved it, but... I understand.

------
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===== ====== ===== The Last Psychiatrist: Greece To Pay Disability Benefits To Pedophiles: America To Report On It

this story is exactly the opposite of what is happening everywhere else in the world

The Greeks started democracy, let's see what they've come up with since then.

ATHENS, Greece (AP) -- Greek disability groups expressed anger Monday at a government decision to expand a list of state-recognized disability categories to include pedophiles, exhibitionists and kleptomaniacs.

The National Confederation of Disabled People called the action "incomprehensible," and said pedophiles are now awarded a higher government disability pay than some people who have received organ transplants.

Also included: "pyromaniacs, compulsive gamblers, fetishists and sadomasochists," i.e. Greeks.

It sounds crazy, it is crazy. Why would they do this?

The government is also battling widespread abuse in the welfare system, forcing tens of thousands of disabled people to be reassessed.

But this isn't abuse of the system, this is the system abusing you. What the hell is going on over there?

II.

FYI: The Illuminati have decided that 2012 is the year the Dow is going to 14000.

Politicians threwout [no sic] the world have a single problem, only one: how to convey the appearance of financial stability until someone discovers cold fusion. Marx was one step off: all costs boil down to energy costs, i.e. oil costs. Fix that problem and the deficits will follow.

The problem of the problem is that the cost of oil has to be high enough for someone to want to discover cold fusion; but if it is high, though not high enough, then simultaneously it will be too expensive for most economies yet too cheap to replace-- or even to extract more of it. Hence shortages. And the cycle repeats.

In the meantime, politicians try to kick that ball as hard as they can down the road. A generation, two, three, far enough out that you don't feel it now.

Social Security and Medicare represent 640% of the U.S. budget. I looked it up. We can pretend that other things matter, but really, they don't. Cold fusion and Social Security. Can't have one or the other, it's both, or neither.

2012 will see an American election between Mitt Romney and President Obama, and the winner will be whichever one of them manages to best avoid questions about Social Security. Unless by November we are finally at war with Iran, Social Security will be the only topic worth discussing, which means we'll be discussing gay marriage.

If you want your generational conflict, that's it. The "old" and their 437 elected representatives will block any attempts to mess with Social Security, or even mention it, and will use welfare and disability-- e.g. SSI-- as a diversion; but they must present the ills of SSI in such a repulsive way that it captures the young's disgust, to distract them from the behemoth that is eating them.

Hence stories about pedophilia. Hence pictures of black people abusing the system. There's one now. He has an XBox. And weed. There's always weed.

The story that comes out of Greece is a prolegomena to any future diversion that will be able to present itself as a news story. For the next year, expect to hear how the disability system is corrupt, corrupting, socialist.

All of those things are true, but irrelevant. The "young" should not fall for this. My track record on criticizing SSI is unassailable, but what is wrong with it isn't the $, but the way the $ are dispensed, i.e through the pretense of medical illness. Almost everyone can work, even a little, at something; imagine if we could get all those SSI recipients to spend 1 hour a day clicking on Google ads. We could be as rich as astronauts.

No. The real problem, the one after oil, is Social Security. Throw in Medicare.

Without real numbers we are not going to solve real problems, so here they are, memorize them:

SSI is $50B. That's it. You could double it, triple it, it wouldn't make any difference. I'm sure the people getting SSI wish the payments were higher, but they aren't not because we don't have the money, but because people hate you. On principle. And it is that hate that both Democrats and Republicans will cultivate; because it reflexively produces a delicious narrative: SSI recipients don't deserve it because they never worked, therefore-- and your mind cannot help but make this a therefore-- Social Security recipients do because they did. I am not saying either of these propositions are right or wrong, I am making the link explicit so you can see what is being done to you. Keep your eye on the black and brown SSI while the government smuggles the old folks to heaven. "Wouldn't this be easier if we had euthanasia?" Done.

SSDI is $124B. SSDI is funded from Social Security taxes (1.8% payroll tax) and represents credits the individual earned while working, i.e. it is disability insurance. But in oral arguments, whether the ex-worker "deserves" it or not will overshadow the fact that he did indeed "pay into it" in some capacity. Look for SSI and SSDI to be conflated into a gigantic "fiscal black hole."

Social Security is $712B. It is funded through FICA, which in 2010 brought in $780B, i.e. $68B surplus, i.e. more than all of SSI. Of course eventually the ABC demo will turn the channel to CBS, and the payouts will exceed the income.

Cold fusion, cold fusion. You gotta have hope.

III.

No one is interested in knowing that in Greece pedophilia is a "disability," but not one you can get any money for. The AP should really talk to some pedophiles before it makes these crazy statements about how much they can earn. (The correct number is zero.) This doesn't mean the Greek government put this law there on purpose so that people could get angry about it; it means the government found it there on purpose so that people could get angry about it.

And no one is interested in knowing that SSI is but a tiny blip on our budgetary concerns, the equivalent of penny pinching to 89 octane when you fill your Escalade. Won't that damage the engine? "What do I care, I'm leasing." That's the most American sentence I have ever written.

What does interest people is "abuse of the system." That, and gay marriage. Romney and Obama will never tire of telling you precisely how the SSI system should be reformed to prevent "fraud and waste", and the press will be happy to report on it. All of those reforms will be financial, i.e. less; none of them fundamental, i.e. more.

"Look over here, everybody. We're protecting your interests. Don't look over there, we're protecting someone else's interests."

Distraction, misdirection. Keep it up until November, or cold fusion, whichever comes last.

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===== ====== ===== The Last Psychiatrist: The Next Step: Suspend The Capital Gains Tax, and The Market

Extraordinary times call for extraordinary measures. Move.

What is happening now is not related to fundamentals. Major companies are being discounted much more than their already lowered future earnings estimates would predict. Stocks are being priced not for recession, but for Depression.

Ten years of growth have been eliminated, and for what? Does anyone even know why they are selling?

It isn't a matter of earnings or even recession; at this level it is all about a lack of confidence. Either stocks have been overly discounted-- yet still there are no buyers, because they lack any confidence in the markets; or they are being discounted appropriately for a coming Great Depression, in which case something more needs to be done to prevent one.

A single sentence on the positives is sufficient: suspending the tax would go a long way to enticing investors back into the waters, whether to ward off Depression or restore confidence.

To those who would express horror at such a regressive notion, consider the following:

1. Suspending the capital gains tax will have a small relative effect to the budget deficit, in comparison to the bailout(s), etc-- less than $80B.

In the years 2003-2005, capital gains revenue was $50B, $60B, and $75B, respectively. Even if the capital gains tax was reduced to zero for one year, the government would stand to lose no more than $80B in mythical money. I say mythical because, in 2008, what capital gains does it expect to tax? Even the short selling was banned.

According to the CBO, in 2002, real estate accounted for 10% of capital gains tax revenue, and stocks 90%. This was during a period of real estate growth and a precipitous stock market fall. The exact reverse situation exists now.

2. Capital gains tax cuts lead to increases in capital gains revenues, not decreases.

Prior to the tax cuts of 2003, the CBO projected capital gains for the years 2003-2005 to be $45B, $44B, and $49B-- as compared to the actual revenues of $50, $600B, and $75B.   In other words, the tax cuts increased revenue by $45B over the three years; they had managed to generate an extra year's worth of capital gains revenues.

One might argue that this lead to asset price inflation which in turn resulted in this collapse; let us grant that this is the case. The tax elimination is only temporary; can be limited only to gains starting after, say, July 1; and one can even raise the tax later. This reduces the lost revenue from $80B to any number desired.

The point is not whether tax cuts do or do not lead to asset bubbles; the point is explicitly to prop up asset prices, so that real investors feel confident to being buying again.

3. 2008 may be the year where one is taxed on losses.

The S&P500 went from 1229 (Jan 1999) to 1469 (Jan 2000), and then back down to 1320 (Jan 2001). It may look like a round trip. But consider that if the 1999's 15% gains were taxed at the short term rate-- to be paid by April 15, 2000-- yet the market was, in that time, falling, one could find himself in the unfortunate scenario of having to pay taxes on gains he no longer had-- in essence, he was being charged a tax just for trying. With that in mind, observe that the 2000 revenues were the highest of all-- $121B. Where did investors who had lost the profits get the money to pay the taxes? They sold the stocks themselves-- contributing further to the already in progress market decline 2001-2003.

4. The suspension can be phased in according to sector.

Clearly, the financials and financially sensitive stocks (e.g. GE) are the root of the problem. One can suspend capital gains taxes on these stocks; as they stabilize, so too will the collateral damage which is-- everything.

Alternatively, the suspension of taxes on dividends can be used to bring investors back into those stocks. Unfortunately, this is the opposite of the current proposal, which is at this time entirely untenable.

5. Suspension of the tax will lead to increased private foreign investment.

In 1994, foreign investment in the U.S. was $50B. This rose to steadily to $3.2T (trillion) in 2000-- and then fell back to $50B by 2002.

After the tax cuts of 2003, it rose back to $1.6T by 2006.

If buyers are needed to turn the markets around, bringin outside investment is an obvious solution.

The Time Is Now

All of these manuevers will take time to implement, and even more time for people to digest and respond to them. Right now, the markets are in a state of free fall with no buyers willing to step in. This is not a market, it is a the dumping of perfectly good bagels into a dumpster because no one wants them. The average 401(k) investor is so perplexed by the happenings that it does not seem real to him-- indeed, it is not real, except for the number at the bottom of the statement. The markets need to be closed, giving investors-- especially large institutions, hedge funds, and rich guys-- time to meet and discuss their terms.

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===== ====== ===== The Last Psychiatrist: The Other Abortion Question

For those who live and breathe the abortion debate, it may be worthwhile to personalize the issue and see if anything changes. Certainly, Rick Santorum has done this.

If you do not already know the story, Senator Santorum told it himself on Fresh Air in September 2004. Briefly, at approximately 20 weeks gestation, he and his wife learned the fetus had a terrible disorder that would likely result in the fetus’ demise. They had three choices: carry the fetus to term, when it would inevitably die; abort the fetus; or try a risky surgery on the fetus (which was still inside the womb) which had a low probability of success. The Santorums, true to their faith and their principles, reasoned thusly: if this was a five year old child, there would be no debate. They went with the surgery.

As tragedies go, this was a big one, as the surgery failed, the fetus died, and the mother suffered complications. However, the story clearly indicates how one should reason if one believes life begins at conception. This is the point for the Senator; it is illogical to argue any differently. If we are debating the abortion issue, this is a hard argument to rebut.

But I am not, here on this blog, interested in the abortion issue specifically; I am interested in another question. It is this:

Who pays for this surgery?

It is not an academic question. Senator Santorum has the benefit of almost infinite medical resources. If we are going to force Medicaid patients to make a similar choice, we have to ask this practical question.

Many are not going to like having, depending on your perspective, a moral or privacy question reduced to money; but that is precisely the problem. Accountability. In the end, someone has to pay.

Only the schizoid will argue that abortion should not be an option even when the mother’s life is in mortal danger; and only the amorally unrealistic will fail to realize that there is something psychologically wrong with a woman who has had three, four, five abortions. (This is not so unusual: it is 18% of all abortions.) You may think it is your right to have as many abortions as you need, and you may be right; but there is still something wrong with you.

Not permitting abortions requires an explanation of how we're going to pay for surgeries like the Santorums's. And if you want to keep abortions legal, you have to tell me how we're going to pay for them; or for any complications that result from them.

Either healthcare is a right, like due process; or it isn’t, like driving. Either one you pick, you must be accountable for the consequences of your selection, for example, its effect on the abortion question; similarly, your stance on abortion must include an discussion of cost. Even if this is,a fter all, a moral question, someone still has to pay for it. I recognize this tarnishes the purity of the academic dialogue. It’s not pretty, it’s not clean, but it’s reality. And if you think that money is not a relevant factor here, then it almost certainly means you are not going to be the one who will have to pay.

This applies to other questions beyond abortion, of course. If someone discovers a cure for AIDS, but it costs ten million dollars, does everyone get to have it?

When the universal healthcare nuts draft a plan that includes how they are going to pay for the unintended consequences of an insufficiently reasoned abortion provision (or restriction), give me a call. Until then, wovon man nicht sprechen kann....

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===== ====== ===== The Last Psychiatrist: The Other Ego Epidemic

so what's behind the photographer?

Some articles sent by readers:

The Ego Epidemic: How more and more of us women have an inflated sense of our own fabulousness

Author: Narcissism is an epidemic in our society.

Newsweek: Generation Me

etc.

I.

"Looks like you were right, even the popular press is catching on to the increase in narcissism--"

Belay that. These magazines are your enemy. Do you think they exist to improve you?

These articles aren't saying narcissism is on the rise, they are saying grandiosity is on the rise. They are conflating the two. Even psychiatrists get this wrong, they are not the same.

Leave aside for now what is the distinction. Look instead at the result: by focusing on the grandiosity, it leaves you, the reader, with an out. "Look at these grandiose idiots. That's not me."   By virtue of the fact that you aren't famous, important, grandiose, you must therefore not be a narcissist. It creates a self-satisfied sense of importance because you're not like them. That's narcissism. These articles actually reinforce your narcissism. They are the wrong kind of friend you've picked to assure you: "that stuck up bitch, what does she know, you're too good for her anyway."

If you're reading it, it's for you.

II.

How can a man who thinks "my wife is way smarter than me!"

or the guy who thinks, "I'm no ladies' man, but I would never use a woman, even if I could!"

or the woman who thinks, "I know I'm not a model, but I'm an attractive, intelligent, independent woman"

-- how can they all be narcissists?

I. I. I. Me. I. Me. I. I. I. I. Me. Me. Me. Enough, we get it, we all know who you are.

It's why happiness always seems out of reach, why love seems elusive or complicated. And sometimes why other people get hurt.

III.

Grandiosity is only one possible manifestation of a psychic process that went awry. The essence, the defining characteristic of narcissism is the isolated worldview, the one in which everyone else is not fully real, only part a person, and only the part the impacts you.

Narcissism is self-protective. It simultaneously allows for the reduction of the other to prop status, while reassuring you that this perspective is not wrong or dangerous because it's not about superiority.

You went to Haiti to help the refugees; great. You may have done it because you want to help; or you may have done it because it identifies you to yourself and others as a kind person, selfless, a helper. Which was it? The former comes from an external ethical structure that informs behavior. The latter is an internal identity that demands validation.

NB: the Haitians don't care either way, just show up.

Narcissism is morally neutral. Only the results can be judged. But it usually predicts: if the boat starts sinking, identity first.

IV.

"I agree. Just do what's right. Don't worry if it makes you suffer now, God will reward you later."

Really? He can't see through that? Which god did you pick out, that he can't see you from the outside, the sum totality of your existence past, present and future?

Of course: you picked the god that thinks like you.

V.

A little egomania isn't a bad thing, especially if it spurs you to be better at whatever you're supposed to be better at. Thinking your the best kid on the playground is not nearly as destructive as thinking you're the only kid the playground. If you don't believe me, try it.

But you think you're the best? Good. Get to work.

VI.

"Help me, please, I think I'm a narcissist. What do I do?"

There are a hundred correct answers, yet all of them useless, all of them will fail precisely because you want to hear them.

There's only one that's universally effective, I've said it before and no one liked it. This is step 1: fake it.

You'll say: but this isn't a treatment, this doesn't make a real change in me, this isn't going to make me less of a narcissist if I'm faking!

All of those answers are the narcissism talking. All of those answers miss the point: your treatment isn't for you, it's for everyone else.

If you do not understand this, repeat step 1.

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===== ====== ===== The Last Psychiatrist: The Other Soprano Psychiatrist

(Finally watching the series on DVD.)
Carmela Soprano, wife of mobster Tony Soprano, is so unhappy in her marriage that she goes to see an old, Jewish, psychiatrist, which is a leap for her as she is not too keen on psychiatrists-- or Jews, for that matter. She describes her ambivalence about her husband:

Carmela (crying): He's a good man, a good father.
Dr. Krakower: You tell me he's a depressed criminal, prone to anger, serially unfaithful. Is that your definition of a good man?
Carmela: I thought psychiatrists weren’t supposed to be judgmental.

Dr. Krakower: Many patients want to be excused for their current predicament because of events that occurred in their childhood. That’s what psychiatry has become in America. Visit any shopping mall or ethnic pride parade and witness the results.
...You'll never be able to feel good about yourself. You'll never be able to quell the feelings of guilt and shame that you talked about, so long as you're his accomplice.

Carmela: You're wrong about the accomplice part, though.

Dr. Krakower: You sure?

Carmela: All I did was make sure he's got clean clothes in his closet and dinner on his table.

Dr. Krakower: So "enable" would be a more accurate job description for what you do than "accomplice". My apologies...
Take only the children--what's left of them--and go.

Carmela: My priest said I should work with him, help him to become a better man.

Dr. Krakower: How's that going?

Carmela: I would have to get a lawyer, find an apartment, arrange for child support...

Dr. Krakower: You're not listening. I'm not charging you because I won't take blood money. You can't either...
Let's pretend that this isn't TV, and that this old psychoanalyst knows something about the therapeutic process. Why say this? What defense mechanism is so prominent in her? What's the single sentence Dr. Krakower can say that changes this conversation from an irresponsible breaking of therapeutic neutrality to a means of overcoming a powerful defense that allows for life decisions based on insight? He says it at the end:
Dr. Krakower: One thing you can never say: You haven't been told.
Therapy isn't about being happy, it's about honestly knowing who you are, and then picking a suitable life. Every day you must consciously choose who you are. Choose.

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===== ====== ===== The Last Psychiatrist: The Other Technical Analysis

the American male may be dead, but the consumer is not

I. The Machines Are In Charge Until At Least 2012

If you accept the proposition that the government is doing whatever it can to prevent further deflation, then you can also say that the fundamentals of the market are at least temporarily being overruled.

If fundamentals are less important, then technicals are more important. The Machines are running the short term show.

Whatever caused the "flash crash" may or may not happen again, but it was inevitable that we would return to that low. Similarly, it was inevitable that the machines will read the red 200dma as a support (next day), the blue 50dma (and arrow) as a resistance, and, currently, that they would see the low back in February (yellow) as a support. It must bounce off that point-- not because the fundamentals warrant it, but because the machines have that locked in as a key point.

It doesn't mean it can't bounce and then go much lower again-- but bounce it must.

II. My Precious

A while ago I noted the unusual finding that gold and platinum were selling at the same price. That's not a world I want to live in. So platinum has raced ahead, now at $1500/oz while gold is at $1100.

The ratio is now fixing itself:

We're still in a deflationary world. Maybe someday we get inflation. But in both cases, gold goes higher (gold goes down during times of slowing inflation.) I thus conclude that in order for the ratio to be acceptable in a universe that does not permit more than one season of Miami Medical, platinum must go even higher. I am aware that the supply of platinum has increased and more is coming, but again, fundamentals matter less in the short term. Plan according to your beliefs.

III.

I'll make three longer term, fundamental points.

1. Stocks

What's a fair P/E for another year's worth of economic nonsense? Assume a PE of 13-15, and S&P earnings of $70, you get 950 level for the S&P. That can be considered a fair value for the S&P.

However, to the extent possible, the U.S. government wants it to be the bottom, and will do whatever is necessary to make it so.

2. Consumer Sentiment

You can measure the economic growth and consumer sentiment through a million abstruse metrics, but for me, as go Aeropostale and Apple, so goes the country.

3. Oil

When the BP oil well blew up in celebration of Hitler's birthday and started leaking 50k barrels/d of precious, delicious oil all over the place, because that's what he would have wanted, you would be forgiven for thinking that it would drive oil prices spectacularly higher.

Nope.

It's all about the value of the dollar and, more importantly, growth prospects here and abroad. In Europe, those prospects aren't good (for now.) That blip upwards on May 10 was when the EU announced a $900B bailout.

You may want to take this as a sign that the supply of oil isn't fundamentally the problem, but rather the demand.

4. When Humanity Gets Together And Decides To Do Something With One Voice, Are They Always Wrong?

This Shiller Imaginarium product surveys the confidence of investors that there will NOT be a market crash in the next 6 months. Draw your own conclusions.

5. Is This The End Of The World?

(previously):

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: The Paycheck Cycle

Problem 1: if you need to point out the card number...
Problem 2: this is not a paycheck

The CEO of WalMart, discussing how he manages the fluctuations in day to day consumer spending:

The paycheck cycle... remains extreme. It is our responsibility to figure out how to sell in that environment... large pack at sizes the beginning of the month, small pack sizes at the end of the month. And to figure out how to deal with what is an ever-increasing amount of transactions being paid for with government assistance.
He is describing how Walmat customers spend more when they get their check, and less at the end of the month.
But:
And you need not go further than one of our stores on midnight at the end of the month. And it's real interesting to watch, about 11 p.m., customers start to come in and shop, fill their grocery basket with basic items, baby formula, milk, bread, eggs,and continue to shop and mill about the store until midnight, when electronic -- government electronic benefits cards get activated and then the checkout starts and occurs. And our sales for those first few hours on the first of the month are substantially and significantly higher.

What's in your mind right now? Above are a bunch of words. What do you infer from them?

Ib.

Clear your mind, just think about this strategically. Ok, these women-- they are women, right?-- are waiting for the government money to be activated. Fine. But why are they there at midnight?

Ic.

And if you really think about it, the only reason somebody gets out in the middle of the night and buys baby formula is that they need it, and they've been waiting for it. Otherwise, we are open 24 hours... But if you are there at midnight, you are there for a reason.
What he's telling you is that on the 29th of the month, kids are running out of food.

II.

The conclusion that there are kids without food is obviously obvious, and undoubtedly you already knew that there were hungry kids in America. But what was your actual first conclusion when you read customers were milling around at 11pm?

Your mind jumped to the causes of that behavior, not the consequence. Are they wasting their money, what?

And your solutions to "that problem" are related to your perception of that person in the store. But the kid didn't ask for this life, and whatever solution you come up with has an effect on that kid. Or, stated more clearly: if your solution doesn't help that kid, it is not a solution; it is a self-aggrandizing political stance. Masturbation is fun, but don't expect anything productive to come from it. And you will be shamed if you get caught.

III.

Note the date on this story: September 2010. What does it mean? It means people in America are struggling right now, living paycheck to paycheck. We hear about the bankers/bailout, we hear about unemployment, but here are some untold stories about the devastating impact of the economic crisis on ordinary Americans.

FALSE. This has nothing to do with the current economic situation, this has been going on for decades. It is framed as related to a current "crisis" so that you are less attuned to the ordinariness of this.

"It's the recession." No, the recession "ended" last year; again, what you see outside is normal. What you saw for the past 20 years was CGI.

III.

Maslow's and his hierarchy suggest that in individualistic cultures, failing to meet basic needs results in anxiety and inhibited development.   So if these kids are underfed regularly at the end of the month, their basic needs aren't being met. So we'd expect them to be more anxious and tense. Hence, psychiatry.

Maybe ADHD is an invented diagnosis, maybe not. But the symptoms are exactly what one might expect when the basic needs aren't met.

Note, however, that the institutional response to this very basic problem is the total mobilization of an unrelated service sector. Medicaid will happily pay $50 a patient visit to prescribe Ritalin, not because Ritalin works or doesn't but because it is cheaper than spending $1000 a month to feed the family.

That's the truth about mental health parity, about healthcare reform. The government needs you to have access to healthcare way more than you actually do.

Or, as Maslow put it: if all you have is a hammer, then everything looks like a nail.

IV.

So we should increase welfare payments?

Won't help. Evidently, middle class Americans cannot effectively manage their own mortgages. Why would we expect poor people to be better at it?

How big a welfare check should be is a separate question. When data reveals widespread patterns of behavior in society (e.g. paycheck cycle), then something in the society creates that behavior. If many poor parents can't manage their families' (no sic) meals, it suggests failure in social services or education.

A simple example. Note the welfare recipients are waiting for their monthly allowance to be activated electronically on their cards. But since it's all electronic, why can't the money be activated weekly? Or, if the data reveal that that results in faster spending (so now 4 days per month the kids are hungry rather than one day), the cards could be filled every 6 months. Or, based on the pattern of spending, each individual would be given the money in different amounts at different times.

V.

The irony: this story occurs at Walmart, notorious for paying people low wages and etc.
That's actually not irony, it is the whole point: labor costs.
The solution that the system has conditioned you to believe is the answer is to give them something. The political divide differs only on what to give them: outright cash payments? Jobs?
What you need to focus on is the why. Solving this isn't a simple matter of raising the food benefit by an amount equivalent to one more day. The system needs to educate the poor on how to live life as a poor person.

But then the system has to confront the reality that it produces the children who are more likely to grow into poor adults as a direct consequence of treating poor people as an aberration of the system, rather than as a fully predictable if unintentional result. In other words, the systematic treatment of poor people as a unexpected result of the system is the very part of the system that maintains the poverty.

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===== ====== ===== The Last Psychiatrist: The Perfect Game: What Would You Do?

If the pitcher has so far pitched a perfect game, and you are the batter in the bottom of the 9th, do you purposely strike out to give it to him?

===== ====== ===== The Last Psychiatrist: The Plan Will Always Fail Catastrophically

unsee it

Still light out.

Driving too fast, there's still patches of snow on this road. But you're almost there.

Turn in the driveway. The house is dark. Crap.

Do not look at the upstairs windows.

Garage door opens. Empty.   Park.

Still light out.

You have about 15 minutes.

Move.

II.

He opened the door, reached in and turned on the light. The kitchen windows still let in plenty of light, but this was just in case.

He didn't step inside. He gripped his mobile phone. Breathe. Dial.

Ring.           Ring.               Ri

"Hi, baby," she said.

Go.

"Hi," he responded, locking the door behind him and wriggling it. The garage is done. He dropped the bag on the counter, not glancing at the window. "How are things there?" He reached into the living room and flicked on that light but did not look inside, then doubled back to the kitchen and headed for the whisky bottle. He took two small gulps, and then a third, then out of the kitchen towards the stairs. Another light, click.

"I'm so tired from being here, you cannot believe words words words words words words." At the top of the stairs he had to make a choice: right had more western windows but would take longer. Last. Go left.

"words words words," his wife said. The phone was in the hand that was turning on the light. The Checklist: windows, closets, cabinets, bed. Windows, closets, cabinets, bed. Bathroom had a shower.

Windows: feel them. locked, locked. He pulled the shades down. "Did you guys have dinner yet?" he inserted.

"No, my mother made words, so we're words words words words"

He opened the closet door. Nothing.   It made an unexpectedly noticeable amount of noise as he closed it, and he reflexively looked over his shoulder. Come on, get a grip. No large cabinets in this room. He fell to the floor and looked under the bed. Nothing. He unplugged the phone. He left the light on, and hurried to the next room. Windows, closet, cabinet, bed. Leaving that light on as well, he left the room and went back down the hallway. That room is completely fine. That room is completely fine.

Next bedroom: light first. He scanned the windows. Both were clearly locked. These windows cannot be jimmied. He pulled the shades down. He slid the closet door open, peeked inside. Nothing. He closed it.

"What are you going to eat tonight?" he heard her say. "Words words words words words."

He lingered at the closet. He had just checked this closet, it was fine. But. But he hadn't really checked the back right wall behind the coats. But it was clearly empty. Don't be OCD, or be sure? No room for mistakes. He opened the closet again and moved the coats. Empty. He closed it. Cabinets, bed. All fine.

The bathroom was tricky to get into, but there was still enough daylight to make it inside. He placed his back against the hallway wall and reached behind him into the bathroom and felt for the light switch.   Click. He rolled inside and looked at the floor and the walls. The shower curtain was pulled open already. Nothing. He shook the shower curtain to be sure.

Then: tap tap

Do not look up. It's a trap.

"Hey," he interrupted, "I was meaning to ask you. When is the baby's next immunization? What has she had already?"

"She has her 9 month well baby visit next week, and words words words words"

Now look.

The medicine cabinet mirror was fine, of course it was fine. He tried to push his finger in through the glass, but couldn't.   Too much light. He opened the medicine cabinet, listened to his wife say some words, braced himself, and closed it again. The mirror was fine. In some horror film a woman was washing her face in the bathroom, and when she bent down into the sink her reflection in the mirror didn't bend down with her, its stayed there and looked down at her. That was just a movie, but it reflected the deeper truth of it: mirrors were the most dangerous things in the house because they were the one place you could be tricked into looking at IT.

Stop. He stepped out and thought about anything else.

You have ten minutes left.

The last thing was the door to the attic stairs. He reached for the handle.

It was locked.

"Jane," he interrupted, "why is the attic door locked?"

"It's always locked. What are you doing up there?"

"Where is the key?"

"I have it with me. Why do you need to get in there?"

"You mean we have no other key?"

"No." Pause. "Honey? There's nothing in there."

The lock was unpickable. He shook it.

"Is it locked from the inside? If I went up there, would I get locked in?" He could suddenly feel the whisky taking effect, calming him, making reality more vivid.

"Well, no, because you'd have to have used the key to open it. If you magically appeared in the attic, yes, you'd be locked in."

He shook it but not so vigorously as to attract attention to himself. It would have to suffice. It was getting dark. Top floor is secure. There is nothing on the top floor.

yet

Eyes widening, he forced himself to focus on his wife. "I feel bad for her that she needs more shots," he said.

"Me, too, the last time she had a fever words words words"

Downstairs.

Within five minutes and during the recitation of the 9 month well baby visit he had performed the Checklist on every room in the house. He had lights on in every room and hallway. Out of the bag he removed a cheesesteak and broccoli, two beers, and with the whisky bottle headed for the living room couch. On the coffee table sat two flashlights and two of his wife's scented candles and a 4 gallon Poland Springs jug filled to the top.   He lit one of the candles and placed it on the far end of the coffee table. He turned on the TV. The moment he saw the local news reporter talking about the real his entire body involuntarily relaxed. 12 hours to go. He could make it.

"All right, baby," he summarized. "You enjoy your dinner, I'll talk to you before I go to sleep."

"I love you." Pause. "Are you nervous in there? Did you take out the gun?"

No guns. "No, of course not. What would I need a gun for?" Guns proved you were afraid. "I'm fine, go have your dinner."

"Ok, I love you. Be safe. Don't burn the house down."

III.

He had known about the Plan since he was 4 or 5. He did not know how he had learned it. The Plan had two parts, The Checklist and The Escape Hatch.

The Checklist had three rules for survival: Rule 1, Important: check all the rooms. Rule 2, Very important: leave the lights on in the rooms he couldn't see. Like with roaches. It prevented them from wanting to come out. Rule 3, Ultra-Important: make sure there was nothing in the rooms that could be turned on. So: batteries out of all toys. Alarm clocks double checked, or unplugged. Phones, especially the phones, had to be unplugged. Only the mobile phone with him was on.

The problem wasn't the unknown, but the lack. In a horror movie the woman would walk into the unknown house and of course there was something relentless and relentless waiting for her. In real life it was the opposite: you knew the house, knew there was nothing in the house. What was supposed to be there-- the kids, the wife, activity-- were absent. So your mind populated the empty spaces.

If you had a weak mind, your mind populated it with imaginary ghosts.
If you had a strong mind

IV.

The Plan could fail catastrophically in two ways.

One: blackout. All blackouts are attacks. If the power went out he had been detected. Using the flashlight to see where he was going would only make things worse, but that's not what it was for. It was for The Escape Hatch.

The other was his bladder.

He could drink himself into unconsciousness. But some point he would have to pee. That meant he had to walk to the bathroom.

The trick was to not see. He could only be seen if he saw, his gaze was what revealed him. On the couch he could divert all his attention to the TV, but if he walked to the bathroom he'd have to unsee the kitchen, the hallway, the bathroom mirror, and everything around him, all while calling attention to himself by his motions, his noise, his thoughts, his fear.

Fear of the dark wasn't that there would be something in the dark, but that you would see something in the dark, the terror was in the perception and not the reality, and even if it turned out to be an illusion or a hat or a shadow that brief moment of terror of what could become possible was too much.

That's what made the long trip to the bathroom so difficult. There were too many things that he had to unsee. He had once thought about getting a bedside urinal bottle, but it was too risky. It would be unusual, it was a physical representation of his fear which would lead to his awareness of what was inside the house. He had to act like everything was normal.

He stood up, took a long look at the TV and tried to empathize with the talk show host as he feigned interest in a movie's supporting actress. Amazing legs. His mind wandered towards her vagina-- then stopped. Not tonight.

There was a clear line of sight from the couch through the kitchen into the hallway and bathroom. Everything was lit. With the interview running in his head, he walked calmly and assertively to the bathroom. In his mind he was asking her if she did her own stunts. He passed into the hallway and didn't look up the stairs.

Facing the toilet, he started to pee. The mirror was behind him.

He flushed. He almost never washed his hands after he peed, but this time he had to-- everything had to be done correctly. No shortcuts. No outward display of fear. Another thought to the interview and he turned to face the mirror. Nothing. He didn't see what he knew would not be there now: his own reflection but turned completely around, facing away, its back to him. He had never seen this reflection yet. When he did, if he turned his head just slightly he would be able to catch a glimpse of the face, his face, proving that it was aware it was being looked at by not looking back. The glimpse would reveal a sad, terrified face. It had been crying. The mouth was gone. Someone had taken its mouth. For minutes it would stare away from him, its sobs barely audible through the ordinarily impenetrable glass of the mirror. Resigned to its fate, it would walk defeatedly away from him deeper into the reflection-bathroom that had been telescoped punishingly into a hallway, and at the end was a wooden door that he should not have in this house. His tiny reflection, trivialized by the distance, would open that door inwards, hang its head in surrender, and walk through. Not having a mouth ensured it would not scream.

He glanced at the couch back in the living room. Just get back there.

He started towards the living room but made it only as far as the kitchen when he heard it.

tap tap tap tap

He froze. Think. It was too clear and too obvious to be a danger. It had to be something real.

tap tap

swish

He took a few steps to the right to get away from the hallway.

tap tap

ah

Yes. Now he was sure he had heard it, it was definitely real so it was defintely nothing. A squirrell on the roof, the heating system, mice, elephants, it didn't matter.

Relieved, he took another step towards the living room and then froze. Oh no.

Because of the steps he had taken to the right, he was approaching the living room obliquely which meant that he could no longer see the couch. The couch was hidden from his view.

He had lost his line of sight. He had been tricked.

He thought about the phone, but that was on the couch. If he ran outside he'd never be able to get back in. Upstairs was madness.

He tried to concentrate on the actress. Great legs. Implants, too. Had to be implants. Had to be. He took a step forward but his concentration was momentarily interrupted.

tap tap tap       tap       tap tap       ta

He wasn't sure if he had heard this, which meant he had heard it.

His back muscles tensed so suddenly that his posture straightened. He knew something was behind him.

He had almost no time. He squeezed all his focus into thinking about the actress curling her toes and walked arrogantly into the room. He unsaw the couch, looked at the TV and went right for the Poland Springs jug. In his peripheral vision and in the safety of the TV's talking he noticed the couch was empty.

He could salvage this, maybe. Sit on the couch. He sat, his foot by the Poland Springs jug.

Do not look up.

Look at the TV, the TV, the TV.

It is above you.

"We'll be right back," the late night host said and it went to a commercial, and in the millisecond it took to fade to black he realized that TV would become the worst kind of mirror, a dark mirror, and he was going to be able to see a reflection in that mirror.

God, please.

In the instant of blackness on the TV he saw it move to the left

ah

It was

And it said: shhhhhhhhhh

The TV never went to commercial, it stayed black. Everything was still. Now he could not help but see what was there all along.

It was peeking around the doorway into the living room. A charcoal grey shape. It is a broomstick. No, it was a blanket draped over a broomstick, like a huge puppet, and the broomstick emerged from the corner of the doorway, creeping slowly, until it was standing fully in the doorway. The handle of the broom poked out from beneath the blanket tapping on the wooden floor.

The blanket was staring at him, because it had two black ovals painted on it, like eyes, and the broom turned so it was facing him.

tap tap tap on the wooden floor

He couldn't move, or else he didn't try to move, nothing moved, nothing did anything except the broom and the blanket which glared at him with big black oval eyes.

"H-h-hi," he whispered to appease it.

Suddenly it withdrew back into the kitchen and the house rebelled against him, from the upstairs he heard the angry, heavy, stomping sound of the worst thing he could imagine, and finally heard the voice he had always unheard

wwwwwwwwwwwwwwwhhhhhhhhhhhhhhhhhhhhhhhhhhhhhe

There was no time to get out, and getting out no longer mattered. The Escape Hatch. He bent towards Poland Springs jug but he was in slow motion, the stomping was coming downstairs much faster than he was moooovviiiinnngggggggggg

Get to it get to it get to it

The whole house was shaking from the rage of the footsteps

just before IT came around into the kitchen his foot cooonnnneeecccttteeeeddddddddd with the jug

enough gasoline splashed out of it to reach the candle

fire is real

The explosion blinded and deafened him. It would be surprised. It had never noticed he had a weapon.

get       to       the                           door

Slow motion again, going too slowly, being sucked back in. And his back was on fire but he knew IT had made it into the living room.

He pulled the front door open, so very slowly but as fast as he could, and just as he felt something brush at his flaming back he was out of the house and suddenly time resumed.

He collapsed in the snow, arm, back, face still on fire. He looked back at the flaming house. There IT was, the blanket on the broom standing in the doorway staring at him, enraged and confused and trapped in a house that would soon be obliterated.

His whole body was in pain but the pain was real and the broom heard him screaming at IT in his mind

burn

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===== ====== ===== The Last Psychiatrist: The Pornography Of Medicine
In which appears the phrase, "the sticky pages of the New England Journal."

Another clinical trial finding that a branded drug is no better than a generic. No one should be surprised, no one is surprised, but the popular posture is to pretend that you were the only one who wasn't surprised and to claim vindication.

That's the posture adopted by the attendees at the American College of Cardiology through their proxy, Inquisitor Harlan Krumholz, who said "You've just seen a negative trial that should change practice, especially the way we in this country have prescribed" the drugs. His prior contribution to medicine was an article about how Canada is better than America. I wonder if Dr. Krumholz would have been so outspoken if the results had found it was better?

But of course, his anger isn't about the ENHANCE study, it's about the role of Pharma.

In truth, the ENHANCE study was devoid of any useful conclusions. Vytorin wasn't worse, certainly-- it was better on a number of really important metrics, but failed to be better (read: was the same) in one metric (intima diameter) which itself isn't a useful one; it is a proxy for a proxy for the ultimate question of morbidity and mortality.

But for something with minimal significance it generated lots of emotion, and lots of internet time. I don't know the official definition offhand, but that's a pretty good one for pornography.

---

Pornography serves no productive pupose, but it allows for a vigourous act of involuted posturing. It is always for masturbation; even when couples use it, it still ends up promoting a kind of mutual masturbation. You're there; your mind isn't.   I'm not judging it as evil or useless, but let's be clear it doesn't advance the species. It's just self stroking. It always seems like a good idea at first, charged with emotion and expectancy, and a feeling of necessity- you need to do this. It sounds great if it's 1:36am and you're both drunk and caffeinated in a Courtyard Marriott in Jefferson City; but... but afterwards you have a vague, empty feeling-- "what was the point of that? Should I have just rented The Empire Strikes Back?"

Pornography looks at the obvious, it reveals what is already known but (un)dresses it pseudo-novel settings to entice, titillate.   It's no suprise to anyone that the penis goes in the vagina, but you want to see it anyway. And so ENHANCE-- and what a great name-- "Let's look at the intima! Let's get close ups! Wow!!"

---

The problem isn't with clinical trials in theory; it is with the obsession medicine has with conducting them, no matter what, for any reason, at any cost, and in the process creating new subtypes of "patients" and "disorders" that don't actually exist. "Dementia related psychosis" or "depression secondary to a medical condition." And meaningless outcome measures: Clinical Global Improvement; intima thickening.

Porn again: there's a fetish for everyone. Some docs get off on intima thickening, I guess, so there will be studies to satisfy, though the benefit to the patient is far from obvious. I'm not saying there's no value in a study comparing, for example, all antipsychotics for efficacy in a convoluted paradigm only a fetishist would understand or care about; I'm simply saying there isn't $60M in value there. If you're actually paying for porn, well, you're an addict.

---

Yet another adjunct study; yet another "open label phase"; yet another "me too" drug; yet another cosmetic indication-- we're not expanding our knowledge base, we are creating froth, we are masturbating. It's no surprise that residents-- people young enough to prefer actually having sex to masturbation-- find more pleasure reading straight science or straight theory than they do from a clinical trial.   As you get older you slow down, I guess, and suddenly a crossover design seems like a good idea.

Why so many clinical trials? Don't blame Pharma, who would undoubtedly be much happier with just an indication and a salesforce. There the blame falls squarely on academics. Discovery is rarely the goal; productivity is. Cover the salary, buy out some of the clinical time; and of course create a name for yourself in the hierarchy. You've made it when you can say something like, "oh, Bill Collins's group over at Yale is studying that, he's a really great guy." It's narcissism, not in a malignant way, but in an entirely easy, natural, self-fulfilling way that can be justified to oneself as not hurting anyone. Hey, it doesn't mean you don't love your wife, or that you don't care about patients. But you've been Associate for two years, and...

And how do you cover a salary? Ask Pharma for money-- and be damn sure to carefully design your study for the outcome you want. I don't have reliable data on this, but I'd bet that most people looking for porn on the internet don't type "naked ladies" into the search bar and hit return. You want results.

There is a downside to masturbation, of course, the most significant being the potential to interfere with your desire to have sex with your actual spouse. So it is with academic clinical trials. Do any patients benefit from the ejaculate in the Journal of Clinical Psychiatry? Do the sticky pages of the New England Journal hold any promise for patients?    And did those studies prevent-- by time, money, or energy-- the study something else more valuable? The answer is yes, a thousand times yes. I'm sure ENHANCE seemed like a good idea at the time. Now, not so much. I think it's great that the AHA has taken the unusual step of denouncing the use of Vytorin as a first line agent on the basis of one single, flawed, study with apparently no serious attention to its findings. What have they accomplished? Nothing, except to solidify the role of pornography as legitimate science.

----

Academia is a regression to adolescence. You're not trying to achieve a goal, you want to make progress towards the goal. "Someday, I'll..." That's it. that's everything. Adolescents aren't confident in the goal, they're not sure they really want it or it's worth it. But there will be all sorts of drama around it.   That's academia. They're not really scientists, their semioticians, not after knowledge but constructs, frameworks.    "Science requires time and diligence-- can't jump to conclusions." Sure. Not like what happened with ENHANCE.

I had expected all this from psychiatrists; it's comforting, but simultaneously horrifying, to know that it exists in the same strength in cariologists as well.

---

I am anonymous, but I am not without character, and I will put my money where mouth is. As of the open Tuesday, I'm in for 500 shares of Schering-Plough, not because I believe in the company, or in Vytorin, but because I know capriciousness when I see it. After everyone cleans up, SGP will bounce back.

Thanks, ACC. You just made me 20%.

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===== ====== ===== The Last Psychiatrist: The Problem With Science Is Scientists

one of these is a false positive, the other is false

I. In case you haven't already heard the story:

In a recent fMRI study, a salmon was shown a series of pictures of human faces showing various emotions: can a salmon distinguish them? and what brain regions are involved. 15 pictures, ten seconds each.

I won't bore you with the anatomy. Because of the small size of the brain, exact brain structures could not be distinguished, but something in the brain did light up. A statistically significant number of voxels, comprising an area of 81mm3 in the midline of the brain, were active (p<.0001).

So can fish interpret human emotions from a picture? I have no idea. I do know, however, that that fish can't do it: it was dead.

II.

Others have discussed the hows/whys of such false positives and what can be done about them. But there are two other problems not discussed:

These researchers chose a dead fish specifically so they could discuss the issue of false positives and why multiple comparisons correction in MRI studies is important. Thus, we know these results are false positives because we know that the fish is dead. Note carefully, however, that both of the things you know are told to you by the researcher; yet you are valuing one as "truth" and the other as "artifact" based on nothing but his word.

The researchers might have been mistaken about the deadness of the fish-- thus nullifying a potentially interesting finding. Or, they could have lied.

There is no way to check. You're rolling your eyes, "why would they lie about that?" or "how would they possibly make a mistake about it being dead?" and you're right, about this they wouldn't.

But what about the old studies?

If they do a study in which an anxious person shows weak activity in the amygdala-- how do you know he was anxious? How wrong about the anxiety do you have to be to invalidate the weakness of the MRI findings? Not much.

III.

The danger of the "false positive" discussion is that it is forward looking: from now on, why should tighten our significance thresholds, change the confidence intervals, controls, etc.   But what about all the prior data that finds only "moderate positive correlations" using more liberal significance thresholds, that may be infected by invalid behavioral assessments--

--that because of the passage of time alone-- not better data, but time-- are now knowledge?

IV.

The biggest problem with MRI studies is that they're hard for the layman to understand. Complexity in science protects prejudice.

Understanding the Anxious Mind, in the NYT Magazine, discusses the science of temperament. Jerome Kagan studied babies, then followed them over the years. Predictably (i.e. what you'd expect the NYT to say), temperament as a baby predicted temperament as an adult, especially in the extreme cases.

They explore the case of the highly anxious "Baby 19" (defined as being distressed by novelty) who, when she was 15, was a plain looking teenager who liked writing, playing the violin, worrying and fidgeting. See? Genetics.

...[Scientists] have put the assumptions about innate temperament on firmer footing, and they have also demonstrated that some of us, like Baby 19, are... born predisposed to be anxious...

...[other scientists] all have reached similar conclusions: that babies differ according to inborn temperament...
You'll observe that those two quotes are about babies-- babies are born a certain way. No argument from me. What they do not say is that the inborn temperament is the reason they are also anxious as adults, but that's the conclusion they make every single time.

"Temperament, it turned out, tended to be stable over those five years, at least in children who started out at the extremes." Its stability is the evidence that the temperament is biological.   If his haircuts are stable over the years, is that biological?

But more importantly, the kids were raised by parents. Parents don't parent in an ideal dispassionate manner, they parent in reaction to the kid in front of them. In other words, kids' temperaments alter the manner in which they are parented, and it's a good bet that the parenting fosters that same temperament. Not a word on that; it's as if it that couldn't possibly be relevant.

And why is testing a four month old's behavior evidence of an innate quality? The first four months of parenting don't count? "Kagan restricted his sample to children who were white, middle class and healthy." Oh. So now all white people are the same?

V.

But that's not real science, real science uses MRIs. If they studied it in an MRI, it must be true.

Teenagers who were in the group at low risk for anxiety showed no increase in activity in the amygdala when they looked at the face, even if they had been told to focus on their own fear. ...In the high-risk kids, even those who were apparently calm in most settings, their amygdalas lighted up more than the others' did.

"Overreactivity in the amygdala" = anxiety. But we don't really know what the amygdala does, nor how it does it, all we know is where it is. Saying something occurred in the amygdala is like saying something occurred in Ohio. "Yes, but we have some sense of what the amygdala does." And I have a sense of what Ohio does, too, it causes trouble in elections and gets its teens to kill themselves.

But at least whether or anxiety is mediated by the amygdala is worth discussing. What you can't do is take a structure that may be involved and therefore conclude that anxiety is an innate trait that is generally stable. Every time I punch someone my shoulder is overactive. Is my genetically mediated shoulder the cause of my alcoholic rages?

And overactive as compared to what? What could possible serve as a control? Seriously, think about this. Point to a guy you believe could be a control in a study measuring what are here defined as subclinical levels of anxiety.

Not every brain state sparks the same subjective experience; one person might describe a hyperaroused brain in a negative way, as feeling anxious or tense, while another might enjoy the sensation and instead uses a positive word like "alert."

None of those words mean anything. Brain state? Hyperaroused? Alert? How can anyone know that the "brain state" that two people are describing differently is the same? These words concepts are so vague that the researcher has to resort to Jungian terms in his descriptions:

The persona can be controlled, but the anima often cannot... Nathan Fox of the University of Maryland says that when the anima erupts in high-risk children, it often takes the form of excessive vigilance and misdirected attention. In the first of his two longitudinal studies...

If you don't even have precise words to describe what you're seeing, how in God's name can you measure it, let alone blame it on the amygdala?

VI.

But research has to start somewhere, and my problem isn't with the researchers or their study, nor do I doubt the relevance of genetics. My problem is that when theory is written up in the NYT, it becomes FACT, it becomes the default understanding. This understanding becomes part of our cultural filter. In the same way porn and Cougar Town has assured us that women over 40 can have satisfying extra marital sex with 20 year old bicycle messengers, we know that behavior is, in large part, genetically determined.

This is how the article ends:

The predictive power of an anxiety-prone temperament, such as it is, essentially works in just one direction: not by predicting what these children will become but by predicting what they will not. In the longitudinal studies of anxiety, all you can say with confidence is that the high-reactive infants will not grow up to be exuberant, outgoing, bubbly or bold.

Think about this. Think about what the average person now understands to be true.

Still, while a Sylvia Plath almost certainly won't grow up to be a Bill Clinton, she can either grow up to be anxious and suicidal, or simply a poet.

VII.

Back to the salmon. The results were statistically significant, but the fish was dead. So we laugh. In 1620, that would have been evidence for the soul, and no one would have laughed.

The problem is the same in both cases. They are questioning the nature of the data. They should be questioning the nature of the fish.

part 2 here.

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===== ====== ===== The Last Psychiatrist: The Problem With One Specific Female Doctor
This is a true story that's going to offend you, I'm telling you that up front.

This is how it goes: the pediatrics attending was attractive, no two ways about it. That's probably not what she wanted you to notice about her but that's the way things go, you have no control over first impressions and even less over second and third impressions. Hold tight to your identity, I sometimes say, because no one else is buying it.

In her defense, if defense is actually needed, she tried to downplay her looks. Hair in a ponytail; glasses on, long dress, white labcoat, modest shoes, little makeup, but as is the problem with some women who don't know the game, all this had the opposite effect. You may get to choose an identity, but you can't pretend to be someone else.

She's talking to the parents of a 4 year old girl. The kid needed an MRI because an ultrasound maybe showed something... "I'm pretty sure it is nothing, but just in case."

Well, just in case isn't just just in case, since it involves sedating to unconsciousness a four year old while her parents look on, visibly anxious, invisibly terrified. The little girl blinks, shakes her head, eyes drift simultaneously north and southwest before she jerks herself alert-- she looks at her parents who gave her the juice and for a devastating, guilty moment the parents think that she thinks that they are trying to kill her. And then she's down. All this, for "nothing."

Sometimes, when a pediatrics attending at a major university hospital says "nothing," what she actually means is "partial anomalous pulmonary venous connection" which, I'll admit, to the untrained ear sounds like two different things, but praise God they are exactly the same.

"Even if that's it," she reassures them before the MRI, "it's one of the more common congenital heart defects, and it's usually associated with another, also pretty common, heart defect, called an atrial septal defect. That's a hole in the septum between the left and right atria." Again, reassuringly.

The father looks at her blankly. "You're saying she could have two heart defects?"

"Well, no, they're both part of the same syndrome. "

"You're really going to have to dumb this down for me, I'm sorry."

She repeats herself.   Just slower.

"The surgery will attempt to patch the defect in the septum and redirect the pulmonary vein to the left atrium."

"I don't follow you."

She tries to use simpler words, but in an attempt to maintain the formalism of medicine, she dumbs down the easy words. "Defect-- it's the hole in the septum." Obviously, this isn't what he needed clarified, because she then adds, "redirect-- reattach."

"I still don't understand. There's a hole in her heart?"

"Let me draw it for you." And there, look, she draws for him an excellent drawing of the heart and vessels, with arrows showing blood flow; then scratches out part and redraws, showing what is normal and what she is worried it could be. It's obvious it's different, anyone could see the pathology.

"But this artery is smaller--?"

"No, that's a vein, but it's ok because after the repair..." She is frustrated, it couldn't be any clearer, what the hell is wrong with these people?

Meanwhile I am watching in amazement. She won't tell them what they need to know.   She wants to tell them facts, not realities. I see her, she is pretty, really beautiful. Distractingly pretty. What does she look like without glasses? Without clothes?   And then I think, why am I thinking this? I'm a dog, I know it, but this is different, the thought "she is pretty" appears like a puzzle, a code, it means something else...

I gently lean over and say, "but what's the relevance to the girl? What does that anomaly actually do to her?"

The father nods, yeah, yeah, exactly-- but the attending looks at me in hostile shock. Then her expression softens, I actually see her create and discharge the thought, "oh, he's just a psychiatrist." She thinks I'm retarded, I know, she thinks I don't know any cardiology at all because I'm a psychiatrist, it never even occurs to her that I may be asking on behalf of the parents, because it never even occurs to her that she's not explaining herself well.   So she tells all of us, in pretend surprise relief, "oh, it just means a left to right shunt, sometimes they're asymptomatic, maybe sometimes pulmonary infections..." Pause, staring. "Shunt. Blood gets diverted."

After the surgery, can she run, play, swim? Hold her breath? "Oh, sure, there's normal oxygenation." What if she gets into a car accident, is she any more likely to rupture a reattached vessel?   Is she more prone to heart attacks in later years? "No, no, she'll have the same risk factors for heart disease as anyone else." She can't say it, she can't say, "no the kid will be normal" because it's not technically exactly accurate, she's a doctor, and she's careful, she's precise.

And there are the lawyers, of course. She always thought it was nothing, that there was no chance it was PAPVC, but the risks of sedating an otherwise asymptomatic 4 year old girl through an expensive test and putting the parents through a week of anxious hell certainly are outweighed by the risk of lawyers, right?

I notice how pretty she is again: a secret message. And I realize that I am seeing her as particularly attractive because she is trying not to be defined that way. She is overcompensating with words, and since no one can understand her they are left only with what they see-- the very thing she was trying to mask. The result is she is incomprehensible except as attractive: "...and you can tell she's really hot underneath all that..." Take a highly technical paper and black magic marker out one sentence, people will spend more time trying to look through the magic marker than they will trying to understand the technical paper. And if they manage to figure out the redacted sentence, it will be assume to be a proxy for the entire paper, even if it isn't.

You can't judge a book by its cover. But if no one understands the book, they will judge it by the cover, if they bother to at all. And if the cover is confusing also, well, forget it.

These parents need her to be real, but she can't be real, her whole professional demeanor is based on the suppression of real.

And that's the problem with this one, single, particular female doctor. I'm not saying this is something that I've observed in other female doctors or that it doesn't happen to male doctors. If you want to make generalizations based on this story, well, that's your own lookout.

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===== ====== ===== The Last Psychiatrist: The Process of Bringing New Drugs To Market

An interview with Alan J. Milbauer, a retired vice president from AstraZeneca and partly responsible for Seroquel, about what goes into the process we're all angry about.

How were decisions made about which drug should be developed?

Mr. Milbauer: We were a company dedicated to finding breakthrough drugs, but we could not afford to put all of our eggs in that basket. So, we needed to consider many factors beyond the breakthrough potential when we chose a drug for further clinical development.

...One example is the drug Zoladex (goserelin) a one- or three-month injectable depot used to treat prostate cancer. This injectable LH/RH analogue suppresses testosterone and might obviate the need for surgery in some cases. Initially, we thought our market would be the oncologists but quickly realized that our real targeted physician group was urologists. Well, urologists are surgeons and we were introducing a treatment that was an alternative to surgery! Although we believed we had a treatment that was good for patients, we had to convince the urologists to store an injectable drug, get reimbursement from third-party insurers, including the Federal government, and forego surgery.

Observe that in this example, the actual efficacy of Zoladex worked against it: the doctors who would use it were, in fact, least likely to want to use it. Do you think they were bad doctors, corrupt and only out to make money? No. their paradigm was cut, cut, cut, even though easy efficacy in a medication was staring them right in the face, they couldn't see it, really see it. Like trying to convince a vegeterian to try a burger. "No way can this be as good as what's been working for me. I'll stick to what's worked for me so far."

But that's the problem, exactly: medicine is practiced by what works for the doctor, not the patient.

How do you change a mini-paradigm like this, when doctors are resistant to data, journal articles, logic? What has to be done is this:

We identified key opinion leaders to work with our drug and ultimately we changed some of their perceptions and practices.
Medicine is not science, it is politics. It is no different than a lobbyist convincing a senator to vote for ANWAR drilling vs wind power subsidies, or both.

The most poignant part of the interview was at the end:

Looking back on your years in the pharmaceutical industry, what was the most challenging part of your job?
Mr. Milbauer: Sometimes I had to convince senior management to drop a drug from development because, in our commercial judgment, the product was unlikely to be successful. The reasons could have been competitive positioning or the amount of commercial resources required, pricing issues, dosing or safety issues, or patient acceptance...but those reasons frequently did not matter to the scientists who had been advocating for the drug. I found myself having to persuade people who had spent many years developing "their" compound that it was not in the company's best interest to pursue the drug, and often these people had difficulty accepting the corporate perspective. But, it was a business after all.
Before you misread this as "money trumps science" go back and re-read the rest of this post. These scientists are not advocating for the cure for AIDS. It could be another Zoloft, or another Celebrex, or another Viagra. What matters to the scientists was that it was their drug, their discovery, their child, sometimes the scientists were vehemently advocating for a drug that was neither important nor profitable.
Part of the problem is that scientists are incentivized on gaining FDA approval, and not future sales OR usefulness.
And that's why the model must change.

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===== ====== ===== The Last Psychiatrist: The Psychological Uncertainty Principle

A commenter, who I believe is a physics undergrad (his blog here) emailed me some of his thoughts on narcissism, and wrote:
...those studies where people rank each other in a room for different attributes having never met them... I think what's going on is we assign people personalities based on how they look and force them to become a certain thing, creating a whole custom world for them...
which puts the idea of "profiling" on its head. Do we actually ever "figure people out," or do we change them into what we think they are by the act of engaging in a relationship (on any level) with them? It sounds a lot like a psychological version of quantum entanglement:
When two systems, of which we know the states by their respective representatives, enter into temporary physical interaction due to known forces between them, and when after a time of mutual influence the systems separate again, then they can no longer be described in the same way as before, viz. by endowing each of them with a representative of its own... By the interaction the two representatives have become entangled.
Which, unfortunately, sounds a lot like this (p. 236):
The unreflective consciousness does not apprehend the person directly or as its object; the person is presented to consciousness in so far as the person is an object for the Other. This means that all of a sudden I am conscious of myself escaping myself, not in that I am the foundation of my own nothingness but in that I have my foundation outside myself. I am for myself only as I am a pure reference for the Other.
You can't know who a person is without relating to them, and once you do that, you irrevocably change them.
Only in relationship to another do you get defined. Sometimes you can do it with your God; but either way, any adjective has to be placed on you by someone else. Are you brave? Strong? funny, stupid, nervous? All that comes from someone else. So when someone relates to you, they define you. You can try to control this-- hence the narcissist preying on the borderline to get her to see him the way he wants to be seen-- but ultimately it's up to the other person.
So we're are, or become, whatever a person thinks we are? No, it's worse than that-- we want to be what they think we are. That's why we maintain the relationship, otherwise we'd change it. ("I divorced her because I didn't like who I became.")
We do it because it is easier, and it serves us. You're kind because he sees you as kind-- which in turn allows him to be seen as someone who can detect kindness. And you accept that you're kind-- or mean/vulnerable/evil/brilliant-- because it serves you-- there's some gain there. But a strong person accepts that on the one hand the other person gives you definition, and on the other hand you are completely undefinable, free, at any moment, to redefine yourself. You can defy him, biology, environment and be anything.
You say: but I can't be a football star just because I want to. But that's wanting someone else to see you in a certain way. Do you want to play ball? Go play ball. "But I won't get on the team." Again, that's wanting to change someone else. Change you first.
But what about-- identity? That's the mistake, that's bad faith. Thinking that our past is us; what we did defines us. Our past can be judged-- what else is there to judge?- but it can't-- shouldn't-- define us, because at any moment we are free to change into something, anything else. And so, too, we can be judged for not changing.
Ultimately, you are responsible for everything you do and think. Not for what happens to you, but for how you choose to react. Nothing else made you be. Nothing else made you do.
Trinity said it best: The Matrix cannot tell you who you are.

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===== ====== ===== The Last Psychiatrist: The Question Isn't Why Do Babies Do It

(From Nature)

The experiment is to grab a bunch of 6 month old and 12 month old babies, and show them a little wooden shape with eyes glued onto it climbing a hill. Then, while a shape is climbing the hill, another shape either comes up behind it and pushes it upwards ("helps"), or a shape comes from above and pushes it downwards ("hinders.")

They then allowed the infants to reach for either the "helper" or the "hinderer."

12/12 six month old babies reached for the helper. 10/12 ten month olds reached for the helper.

(Standard science disclaimers apply: further experiments showed it wasn't the shape or color; nor the direction of the movement, only the coupling of two in a helping movement that was preferred.)

So either the babies prefer helpers, or they are averse to hinderers. To test this, they ran the experiments pairing 1) helper scenario vs. neutral, or 2) hindering scenario vs. neutral. In 1) 7/8 babies chose the helper, and in 2) 7/8 babies chose the neutral. In other words, babies both prefer helpers and are averse to hinderers. Awesome. If I need backup, I'm calling a baby.

So we have a situation where the overwhelming number of babies prefer "helping" and like to avoid "hindering." Is this innate? The age suggests it may be (and the same team has similar data on 3 month olds), though at least one psychologist that Yahoo! asked said they more than likely learned these behaviors from observing adults, etc.

But the question isn't why do babies choose this way.

We have to assume these are randomly selected babies, and they overwhelmingly and homogeneously chose helping.   The real question is why, if presented with a similar choice, do random adults not overwhelmingly choose this way? If it's innate, why do adults lose it? If it's learned, why did they forget? If these are indeed random babies, then presumably all/most humans were once like this.   It's possible that some babies never learned it-- they lived in households were helping wasn't rewarded or modeled, etc. But what about everyone else who chooses the bad guy? The most likely explanation is that we learned it, but ignore or overrule it. Make choices based on other reasons instead.

You can imagine a billion different "reasons:" the guy wants to appear tough/cool. (Like cheering for the bad guy.) Deep jealousy or envy over anything symbiotic. Paranoia about anyone "pretending" to be a helper. Double bind. A will to power. Whatever.

But what becomes clear, if you work it through this way, is that whatever the reason, it was a reason chosen. There was no compulsion, anymore than one is compelled to choose pizza over pasta-- it is a preference born of a myriad of factors, but a preference nonetheless. You were someone, and you become someone else.

Inevitably and unfortunately, you get to pick who you are.

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===== ====== ===== The Last Psychiatrist: The Rage Of The Average Joe

all of this has happened before and it will happen again

"Obviously his methods were wrong, but you can see how a person can feel so excluded..."

"Of course he shouldn't have killed anyone, but you can understand the frustration of a guy who does the right thing, but still gets the shaft, meanwhile these other guys get everything handed to them..."
"You know, he does have one legitimate point..."

"All I'm saying is his explanation makes total sense..."

"Look, I don't condone what he did, but I can understand..."

etc.

II.

Of course his explanation makes sense. What did you expect? Numerology? Bible codes? He's not insane.   The man could just as well have railed about blacks or illegal immigrants. It would still all make sense, it would all be internally consistent, and it would all be wrong.

Look up there. See those quotes, those justifications? Those are what people said-- after George Sodini shot up an aerobics studio. They're the same hedges despite completely different events. That's because the content is a red herring.

If he had blamed the RAND Corporation and the reverse vampires, would you have listened? But since "IRS" seems plausible you overlook the paranoia.

What people want is to take his possibly legitimate frustration, and extend it to his actions. "Since he was so frustrated, he eventually snapped." The note tells you why he was frustrated, but it does not tell you why he killed anyone. If you want to use it for the former, go ahead. But the note is as informative as Mercury in Libra for the latter.

III.

"But the note says the IRS made him do it."

Funny: Sodini's note said he did it because he was about to lose his job, but still it's blamed on a lack of sex. You know why? Because no one cares why Sodini did it, they just want to talk about their own gripes. "Women are bitches." "Men are misogynists."

In this case, people are going to use it as "see how the government drives people crazy?" and simultaneously by others to as "these anti-government nuts are crazy."

In other words, if you're reading it, it's for you.

IV.

"Was he a right wing nut? I heard he was a socialist nut?"

It's natural to look at this from your own perspective ("he has a point about the rich" etc) but this isn't a manifesto, it's a suicide note. The information of suicide notes are not reliable.

And it's a suicide note, not a homicide note, because it is about his life/death. Everyone else doesn't matter.

The reason why he's so hard to pin down as right wing or left wing (or patsy) is that it's not important to him, writing the note. The purpose of the note isn't to convey information, it is to convey mood, and the seemingly random and contradictory positions he takes on issues is all in an attempt to win you, the reader, over to his side. He knows for sure he is angry, he knows for sure he feels wronged, but he can't logically and realistically link the real world events to his level of anger. So he confuses you with words while blanketing you with mood. You have no idea what he's talking about, but you definitely sympathize with the frustration. Boom-- he got you.

If you simply look at it as a "type", then he's a mass murderer, akin to a guy in a tower with a rifle. So the form of the note will be impotence, paranoia, displacement, a feeling of rejection/invalidation, and, of course, narcissism. I'll make the simple observation that as obsessed with rules as he was, he didn't think and didn't like that they necessarily applied to him.

The reason this is important-- that you should focus on the form of the note and not the content-- is that it speaks to "treatment" and prevention. If you had granted every single one of his wishes, he would still not have been satisfied, he would not have been happy.   As bankrupt as he was, he still had a plane, a house to set on fire, a car... note also he didn't seem to care about his family he left behind. The problem isn't what happened to him in his life, it's how he viewed his life and its expectations.

I'm not saying he would inevitably found a reason to explode, or that rage against the IRS was not a factor.   He may not have someday flown his plane into an old high school bully or a cheating wife-- or maybe he would have-- but it's wrong to think of this as an ordinary man crushed under the weight of regulation.

This was a keg of rum rolling around a smoldering ship. Maybe he blows up, maybe he doesn't. Either way, abandon ship.

V.

Commonly heard after an event like this: "he was so nice, I can't believe it he did this."

"We didn't know that he had frustrations and troubles," said Pam Parker, who had known Stack and his wife, Sheryl, for several years and last spoke to him a few weeks ago.
"He always was very easygoing," Parker told the Austin American-Statesman. "He was just a pleasant friendly guy."

You're surprised because you think you knew him because of the duration of your exposure to his body and the sounds his mouth made; but they don't put themselves into their relationships, they put themselves into appearances. The rest is just going through the motions.

VI.

Why hasn't this happened before? Or: why isn't this being called terrorism?

Because the media says it's okay to shoot women, but not okay to don suicide vest.

We have already accepted-- not acceptable, accepted-- methods of American violence, and the media has a backstory for all of them, right or wrong: The 70s was serial killers-- "caused" by childhood sexual abuse. In the 90s we had school shooters, "caused" by bullying. We have one for random violence against attractive women: loser loner, caused by (either) no sex or . So we can all be horrified, but not surprised.

Now we have a template for a new kind of violence: anti-government Average Joe.

Unfortunately, the creation of this template-- the repeated discussion amongst pundits that "we don't condone but..." and then a dramatization on CSI or in a movie, means that Average Joe mass murder is going to be inevitably part of our culture.

But none of these templates are true, in the sense that there's no causality. They are merely post hoc descriptive. And since dead men tell no tales, you can pretty much describe one any way you want, for your own purposes.

If Joe Stack had reflected on that, he would never have hit the ignition.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: The Real Mystery of 'Lost'

Figuring out when the hell the show is going to be on.

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===== ====== ===== The Last Psychiatrist: There Is No Link Between ADHD And Organophosphate Pesticides

come on you guys: what do the authors want to be true?

Pediatrics has a now famous study in which it was found that kids exposed to certain pesticides had significantly increased risk for ADHD.

There is universal praise for this piece of garbage, bow to the only true god: Evidence!

Michael L. Goldstein, MD, who was not involved in the study, said the study results are "very interesting findings from a very well-done study from a good database." The report, he said, "certainly got my attention when I read it; I was really impressed by it. I think it is a groundbreaking study..."
There are no dissenters, the worst that is said is "well, correlation isn't causation."

Sorry, there is one dissenter-- a pesticide rep:

Garry Hamlin of Dow AgroSciences, which manufactures an organophosphate known as chlorpyrifos, said he had not had time to read the report closely. But, he added, "the results reported in the paper don't establish any association specific to our product chlorpyrifos."
Ha! And the fact that he objects must mean it's true. (Never mind chlorpyrifos was specifically not associated with an increased risk in this study.)

But the problem isn't the data-- in psychiatry, the problem is almost never the data.

The study purports to show some relationship between pesticides and ADHD. But this is silly; a priori, pesticides at high enough doses disrupt cognitive function. Duh? So what's the point of the study? Have they found that kids are getting exposed to much higher levels to pesticides than we ever thought? Or that the pesticides are even more toxic than previously known? No. So?

The purpose isn't to show that pesticides can cause ADHD; the purpose is to solidify in your mind that ADHD is real.

While you're busy teasing apart statistical or methodological issues, such as whether a single static urine sample is sufficient to infer pesticide exposure in general, or the lack of control for diet, or how did they calculate the odds ratio? you are not questioning whether ADHD is a real disorder, and that what they say it is here is what others say it is elsewhere.

But it's a trick. You cannot use a correlation between two variables to prove the validity of one of the variables.

You cannot use a statistical correlation between pesticides and ADHD to reinforce the validity of ADHD, but that is what they did. And everyone fell for it.

II.

Note that the rate of ADHD in this study (12%) is double the national average. You don't have to agree with me on this, but: that national average is likely inflated, i.e. kids were diagnosed ADHD that should have been bipolar, or anxious, or normal. So whatever happened in this diagnostic sniper attack (telephone interviews of parents, and did not exclude symptoms that could/did occur in another disorder) is suspect.

Regardless, it is indisputable that under the best circumstances-- a two hour interview with PET scan and genetic testing-- the diagnosis "ADHD" is not biologically homogeneous. Whatever Billy has, even if it appears identical to what Jamal has, may be biochemically completely distinct. Early HIV and the flu both appear identical in the beginning, but I'm not having sex with either.

This doesn't mean that "it doesn't exist"-- the behaviors are real. Nor does it mean the same medicine (e.g. Adderall) can't help it/them.

So now to the study, which finds a correlation between pesticides and an increased risk for a report of a cluster of behaviors. No argument from me at all. But the rigorous explanation of this study is that pesticides increase the risk for these behaviors, not "ADHD."

III.

If I've lost you, think of it like this: if this study found not just correlation but causation-- if the study proved that pesticides actually caused all of the symptoms that are detected by the ADHD inventory, then that isn't ADHD, any more than psychosis caused by cocaine is the same as schizophrenia. This would be pesticide poisoning. And if you're treating it with Adderall, you're an idiot.

IV.

Stated explicitly: the purpose of these studies is not to establish a link between variables, but to gain popular support from the public for one of the variables so that it becomes insanity to ask whether it's real.

Here's an example. If the study determined a link between pesticide exposure and IQ, you'd say, "oh, I guess that makes sense that pesticides would lower intelligence." If you do enough of these studies, say, 10,000 of them, you wouldn't have learned anything more about pesticides and intelligence-- because what else would there be to say? but you would have drowned in the passive assertions that IQ measures intelligence. So it would become insane to question whether IQ is a good measure of intelligence ("oh come on, you're not asking rigorous questions, we've been doing it this way for decades"). At best-- another trick-- the debate may turn towards whether the Wechsler test is a valid measure of IQ.

Maybe it is, maybe it isn't; but there are other kinds of studies that would tell us that. You can't use these correlation studies to reinforce the validity of IQ. But that's what would happen,10,000 garbage studies later. "Oh, yeah, IQ. Everyone knows about that."

V.

"You're just silly. You haven't discussed construct validity..."

If you had this thought, then you're the problem. I have discussed construct validity, without saying the words "construct validity," because the words distract from the discussion. Same with "statistical significance." But that's the move, drown the public in jargon and they'll cling tightly to whatever they do understand, which in this case is the title: "Pesticides linked to ADHD."

Every second you spend talking about construct validity is a second you aren't talking about the fact that the kid in front of you has something far more serious than ADHD.

If you are a talking to a scientician and they say "construct validity" or sling around a chi-squared, grab their tie and slam their face into the desk, and then run, run, run, you are being lied to.

VI.

"Why didn't you publish this post earlier, when the story first came out????"

You mean because the further away we get from the hot news cycle, the less you're interested in the truth? And so apathy allows it to stand as true, because it all seems plausible (face validity, bitches.) That's social science for you.

But the answer to your question is simple: I don't get paid to criticize studies.   I have a job and a life and an alcohol problem that doesn't leave much room for blog posts.

If you don't like something going on in politics, there are ways to voice that. But looking deep into a "scientific" concept requires a level of sophistication which, if you possess it, means you're probably busy with a day job. So you have neither the time nor energy to dissect articles in Pediatrics-- and, anyway, no forum. I, at least have a semi-popular blog; but even so I'm subject to the same time and monetary constraints. If I need money for rum, do I spend an extra hour at work, or write a post?

Had it not been for the little money I do get from this blog, maybe I would not have written this post at all, because... why bother? And so all you are left with is their dogma. Search the internet, the Letters To The Editor. Anyone else saying what I just said in this post? You may not agree with my post, but you are nevertheless better for having read and considered it.

I'm not saying I'm the only one who thought it; I'm saying that those who thought it, or could have thought it, are busy with other things, and the people who should have thought of it physically can't.

What do you think would happen if the NIMH paid astrophysicists to look into psychiatry? Ain't never gonna find out, they have their own problems. Specialization doesn't mean I'm the best, it means stay off my lawn.

Since I/us/astrophysicists don't have the resources to publish at all/as fast as Pediatrics or CNN, they get to decide what's true.

The people who get paid to look at ADHD are all unanimously on the same side, that's what conveys the illusion of objectivity. Pretending to be divided pro- or anti-Pharma, or "dopamine hypothesis" vs. "noradrenergic hypothesis" makes it look like there's a lot of vigorous debate, but debating what color is a ki-ran just means ki-rans are real.

Please don't misunderstand me, I am not blogging for money. I'm showing you that so much of what you think you know, what you think is fact, is established not by the force of evidence but by the absence of resources for the opposition. The ones with the money are all unanimously in agreement.

So yes, I would have liked to have posted day one; but I would have liked it better if someone else on the inside said, "umm, wait a minute? Really? We're going to CNN with this?"

-------
http://twitter.com/thelastpsych

---

More on pesticides here.

Note: I added another section to the earlier Love Means Not Letting The Other Person Be Himself.

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===== ====== ===== The Last Psychiatrist: The Scariest Thing I Have Ever Seen

And it's wasn't this.

I went to see the remake of Halloween by Rob Zombie. I've seen a lot of horror movies in my life, but John Carpenter's original Halloween was one of the best-- and I can prove it.
There's an important psychiatric difference between the original and the remake. In the original, you don't know Michael Meyers. At all. We know a little of his background by description only. We don't know why he has to kill everyone ("rage" is the single unsatisfactory answer offered.) He never talks, never runs, never jumps, never emotes, nothing. He doesn't even die, he pauses. He's a robot. You never see his face, either. He wears a mask, but that's basically his real face. He's not a human being, he's a force of evil. There's no person there to rehabilitate. You don't incarcerate him, you set him on fire. (It doesn't work.)
In the remake, however, Michael's childhood is graphically portrayed. Cursing, torturing animals, horrible parents, stripper mom, etc. Now, he's a person. All his future murders are part of that context. Is he responsible? The product of his environment?
Does it matter? You butcher 40 people, and that's pretty much all I need to know. But now I've sat through thirty minutes of his childhood, so it inserts itself in my judgment. To some, that's why you need to know the context. To me, that's the distraction to the truth of the behavior. I don't want to know why he's butchering people. I want to know if fire will stop him. (It doesn't.)
It also makes the movie suck: before, you were terrified of Michael Meyers. Now, you're not as scared, and you hate him. You know why you hate him? Because he's a person.
But that's not the scariest thing I have ever seen.
Let me start by saying the movie is brutally graphic-- torture porn. How this thing didn't get an NC-17 is beyond me. The cursing alone hits you-- it's diarrhea, flowing, disgusting. The violence is beyond overkill, it is relentless. Jesus, we get it, stop killing the dead girl! The movie is also profoundly loud, in the horror movie vein: quiet quiet quiet DEATH!!!!!
Plenty of naked women, very naked, I'm not sure how you can be more naked than naked but somehow they are-- and they get slaughtered. The link between sex and violence is smashed into your skull. I defy anyone to get an erection within a week of this movie.
The movie is draining. By the end of it, you are just exhausted, empty, numb. Nothing you see in the real world has any energy or affect attached to it, because you've been supersaturated by affect. You need a drink. A lot of them. Whisky. And you are completely sickened by all of humanity. The original Michael Meyers made the "right and wrong" distinction so much more visceral. This just makes you want to vomit on everyone you see. You think: every person could be a potential Michael Meyers given the right/wrong family dynamic.
The violence is brutal, long, rageful, it is hate, hate, hate, and the victims aren't killed, they are obliterated, like a jack-o-lantern on a Detroit mischief night.
Which brings me to the scariest thing I have ever seen in my entire life.
So I go to the 1015p showing, along with the usual crowd of degenerates who need to see this kind of movie in the theatre at 1015 pm on a weekday. Not criticizing, just saying.
Midway through this gore fest I need to go to the bathroom. Or maybe I just need a Zyprexa. But as I walk down the steps, I see something that literally makes me freeze: for a second, I actually die.
On the screen is a murder so grisly I cannot actually describe it, but I don't even see it, it doesn't register at all-- I'm looking instead at this. What I see cannot be real.

A second later I breathe, and it's an audible gasp. And what I see, what I see-- is this:

Maybe the picture is too dark. Or maybe it's your unconscious deliberately blocking it out. So I'll tell you: it's a double stroller.
I'll also tell you that after the movie I waited in the lobby to see-- what did I expect?   It was a five year old girl and a three year old boy. And an infant. They walked out like it was nothing. A man and woman, in their twenties-- and since you're asking, both white and obese-- pushing two kids, 3 and 4? 4 and 5? They walked out like it was nothing.
The other people now in the lobby were murmuring, whispering, pointing, but not about the movie --? ---!!! ---???? No one could believe it. Even the degenerates were horrified.
By this time it's about 1230 am. The boy yawns.
I found myself inventing the most insane justifications: they slept through the movie. The parents had fortunately given them all a Xanax-- or maybe they're deaf and blind? Maybe they were under a blanket watching Nemo on DVD.
In Lancet there's a study linking ADHD to food additives. Because, you know, that matters.

Addendum: given the controversy this article has generated, I've posted an explanation and apology.

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===== ====== ===== The Last Psychiatrist: The Second Story Of Echo And Narcissus - Audio

Buy Now-- mp3 format

Buy Now-- m4a format

m4a for Apple products, everyone else mp3 unless you know what you're doing.

18 minute story. $2.00. After you pay, you'll receive an email with a link to the download.

In a few months I will make this into a free video, and I will post the free text of the audio as well. So it's up to you whether you value... whatever this site is.

Don't tell me I shouldn't use a Blackberry mic. I know that now.

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: The Sex-Starved Wife

On the one hand, you have articles in the Economist saying people are spending less time at work and more at home, on the other hand Time writes about the sex-starved wife. If they're both home more and at work less, why aren't they naked?

The answer isn't porn.

Sex is a good proxy for a lot of things. The Time article offers a number of explanations for why a man might have a lower libido than his wife, but not the correct one: narcissism. In women, narcissism manifests itself as a greater libido, and in men, a lesser one.

You might think this is backwards, but it isn't. The wife is more involved with every part of the relationship-- the money, the jobs-- his and hers-- the troubles, everything-- that the man has no way to construct an artificial identity she'd believe. He can't pretend he's anything-- suave, a major force at work, a successful investor, whatever-- because she knows his reality in text message speed. She talks to her husband not once, but four or five times a day. What's he going to say she doesn't already know? Even legitimate successes are subdued because they are not at all surprises.

Here's the mistake: women say, "but I get turned on by him anyway, he doesn't have to impress me, he has me." And my unscientific poll of... some... women suggests they are more sexually open and experimental than ever. So what's wrong? And so maybe the wife thinks she's not hot enough? And catchers his glances at the waitress, the porn on the computer.

Well, the problem with his libido isn't how hot she is.   He's a narcissist: the problem is his libido is that it depends on how hot he is.

It's what women used to go through. He looks in the mirror, sees a gut-- he doesn't feel sexy, he can't imagine she would find him sexy, so the libido falls. In the past he could at least draw confidence from the fact that he has a good job; but now he doesn't have a "good " job, it's an okay job, one that pays the bills, but not something that you can build an identity with. And anyway she has one just as good. What's his appeal?

The woman, by contrast, might actually feel better about her deteriorating body because she's attained value in other ways; and so she figures, "we are aging together." A narcissist does not want to hear that, ever. He can still penetrate you if you become old, fat and ugly; he can't do it if he becomes old, fat and ugly.

It's a double whammy of feeling emasculated, while his narcissistic personality structure demands that he be hyper-male, ideal male. He can't attain it. So he thinks you see him as less than masculine. So he doesn't bother with you.

So the wife asks, "is he picturing himself with other women when he has sex with me?" No; he's picturing someone else with other women when he does you. It's masturbation. It's not sexy if it's his bloated body underneath Sports Illustrated's Marisa Miller.

It's what the relatively recent fascination with MILFs is all about. The fantasy isn't that your wife is with another man; the fantasy is that your wife is hot enough that another man would want her. But this fantasy has nothing to do with how hot your wife actually is, it's about your identity: I'm so great that such a woman would want me.

Consider the cover of the book, The Sex-Starved Wife. She's not starved because she's ugly. Get it?

And so, to the diversions. If you're married and your husband plays WoW, forget it, he's lost to you. He's playing it because it rewards him with the kind of validation only successful daytrading might give him (and it won't.) The online porn; the glances at the younger women around him. It's not (just) that he finds them attractive: their real appeal is that they do not know him, and with them he could be the man he thinks he should be because they wouldn't know it's an invented identity. And the younger and younger ages of the women isn't about pedophilia-- he's just unconsciously dutch auctioning in on the age naive enough to believe his created identity. He starts at 30, goes to 20, maybe 18, then 16...?

Interestingly, articles about the sex starved wife are in the current environment of declining, not rising, divorce rates. For a number of reasons, couples are bonded together more tightly than before. Divorce is somehow out of the range of options; commitment means something again.   Parents spend more time together and with their kids. Sounds great. Still: no nakedness.

They are staying together, but they are less emotionally connected than ever. Narcissists cannot connect.

Let me be clear that I am not using "narcissism" as a pejorative term, I'm just describing a personality structure and its consequences.

By the way, don't think you're not a narcissist because you're 30 and having sex every day; the involution, the self-absorption gets unmasked as natural aging slows you down.

And so, too, kids, the saddest generation of the past 100 years. Why? Because even though Dad is around more than any other generation, he is less emotionally involved. Sure, he's home five hours a day; but three of them he's irritable, short, or outright yelling at them. Kids don't think, "what the hell is wrong with Dad? He should get himself a drink." They think, "oh my God, I must suck. I'm going to get a drink." Alcohol use among teens is going to rise substantially, you heard it hear first, because alcohol is the drug of the lonely surrounded by everyone.

Oh, you want a solution? Here it is: have sex. Even if you're not in the mood.   It seems like strange advice-- force yourself to have sex-- but it's the correct advice. The problem is unrealistic expectations of yourself, sex, marriage, etc. Instead of fantasizing, pretending, teasing, silly text messages that come to nothing, whatever, just do it. If nothing else-- and this is nearly unimaginable-- you will both feel better that you did it, that there's nothing wrong with your marriage.

"But I'm tired." Jesus Christ, have a shot of rum, and get to the penetration.

---

More: what happens to boys when girls are too hot, and A Quick Word On Porn's Effect On Your Penis
.

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===== ====== ===== The Last Psychiatrist: The Sopranos Finale Explained

We meet at our regularly scheduled Monday lunch spot, and my friend says, "did you see the Sopranos finale?" No. "It sucked, nothing happened. It was completely unsatisfying. It just ended with him sitting in a diner, eating with his wife."
"What did you expect would happen?"

"I don't know, something, some closure. Maybe he gets whacked or something."
"How did it end?"
"He's just sitting there, eating an onion ring, and Journey's playing, and suddenly it ends. Like the film broke. And they go right to the credits."
I had never seen an episode of the Sopranos, but I knew at that moment that Tony Soprano had died.
Before I explain, I'll tell you that last night, drunk at a hotel bar around midnight, there was The Sopranos on the TV above me.   It was the last five minutes, but I recognized it immediately from my friend's description. Tony sitting in a booth, his wife slides in and he gives her a grunt-greeting reserved only for the most familiar of contacts-- beyond love or friendship-- then another guy comes over and joins them.
Meanwhile, suspicious characters abound-- the Member's Only jacket prominent, a signal of belonging vs. exclusion; his daughter trying to park the car-- figuring things out on her own, she'll get it eventually-- and, of course, Journey's Don't Stop Believing.
And, like my friend said, the show simply stopped. The bar I was in had been silent-- but a collective groan arose when the credits rolled. Everyone hated it.

I was right. He was dead.
I knew he had died because I knew my friend. He is a human being living in our times, possessing an element of natural narcissism common to all of us. Remember, the narcissist believes he is the main character in his movie. This is why they-- we-- have such trouble with death. In any movie or show, even when the main character dies, the movie continues (the movie never ends/it goes on and on and on and on). It is still about him-- you see the reactions of other people to his death, you see consequences.
But in reality, when you die, it ends. There's no more; you don't get to see the reactions of other people to your death. You don't get to do anything.
I knew Tony Soprano was dead because it was too abrupt, too final, for my friend, and for everyone in that bar. There was no denouement, there was no winding down, no debriefing, no resolution. Not even a struggle for survival-- at least let him draw his gun! No death on your terms. And, most importantly, the death didn't seem to flow logically from the show. The death made no sense, it was arbitrary. It was unsatisfying.
In other words, it was too real.
We all have an element of essential narcissism in us, that's part of having an identity. But it alters our relationship to death. We want it to flow logically from our lives, and most of the time it does. But sometimes it doesn't. Except for heroes and suicides, no one gets to choose the time and place of their death, nor the manner. Nor can we control people's reactions to our death.
All we can do is choose the life we leave behind. Choose.

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===== ====== ===== The Last Psychiatrist: The Source Of Society's Ills

hint: it's the guy on the right

(Part 1 here)

Richard Wilkinson, epidemiologist, looked at data to determine if numerous social ills-- from crime to teen pregnancy to mental illness-- are caused by any one single factor.

In fairness, he knew in advance what he wanted the answer to be, so when he found it it wasn't so much a surprise as a potential 350 page book available at Amazon. But data is data.

One might accuse me of misrepresenting people's ideas, so I'll give Wilkinson the first word:

[Aside: did this make you angry? Realize your anger is directed at the people, not specifically the ideas even though you disagree; you hate the kind of people you imagine this video represents. Empty political discourse reinforces a division among people, not ideas. Not only did Wilkinson fail at winning you over, he's made it impossible for you to even consider listening.]

The single cause that he found isn't poverty or a lack of economic growth. What Wilkinson did not find-- and what too many other intelligent people think that he found-- is that income inequality is the cause of society's ills. The problem is not that your country has too many poor people:

The single cause is relative inequality. Those 25% Americans who live 50% below the average income still have a lot compared to Slovakians; but they're sicker/unhappier than most Slovakians because they are poorer than other Americans.
Wilkinson makes explicit that the relationship of relative inequality to social ills is
nation specific (Americans compare themselves to other Americans, not Slovakians)
in one direction: crime/obesity/unhappiness is caused by income inequality, not the other way around
and implicitly that the issue is not necessarily an inability to access services (e.g. health care) but a relative inability to participate in that society. By analogy that is not at all a joke: the problem isn't that you don't have a million dollars, the problem is that the other guy does, and now he doesn't want to hang out with you.
Wilkinson has numerous solutions, previously discussed at Starbucks, of varying levels of efficacy or insanity, depending:

progressive income and property taxes
good labour law, protection of union rights
more generous pensions
higher minimum wages
ceiling/maximum wage
etc.
It's important to point out three things:
Why he titled his book, "The Spirit Level:" Not a reference to living free of materialism, but rather a carpenter's tool to check and see if things are level. There's no "invisible hand" at work here.
Wilkinson is not just another academic social policy theorist who references Marx; he is also the editor of the 2003 version of the WHO report on social justice.
Despite Wilkinson's explicit reference to inequality being judged within a specific country, the WHO report extends it to cover all countries-- so it doesn't just call for income redistribution within your nation, it calls for it across the world.
So we're back to the beginning: what does income redistribution have to do with medicine? Since it is apparently the cause of numerous social ills including crime and war, why is it the role of one of them (health) to start the process, and not, say, the Department of Corrections or the military??

What, you think doctors are just better humanitarians?

Part 3 here

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===== ====== ===== The Last Psychiatrist: The Special Circumstance Which Causes The Wisdom Of Crowds To Fail
Maybe 300 or so psychiatrists, gathered at the meeting.

Why the Wisdom Of Crowds works. Now why it doesn't.

The audience was shown 8 multiple choice questions as a pre-test.   Everyone entered their response into their personal keypad, and after each question the presenter showed and explained the correct response.

We were also shown the audience's answers distribution. In half of the questions, the majority chose the right answer. In the other half, the correct answer was tied for most responses. I was a little surprised, thinking that the wisdom of crowds would clearly result in the right answer every time. So it goes.

The presenter then went through his lecture, and then showed the same 8 questions.

Wow. This time the majority never picked the right answer.

I want you to stop and think about this. We had all seen the questions before; we had been told what the right answers were; and we were given a presentation on the material. Not only did "the wisdom of crowds" fail, it did worse than it had initially.

It did worse than worse. The wrong answers weren't randomly distributed. Each time the majority chose the same wrong answer.

What happened?   Say what you want about psychiatrists, they're not retarded. So?

II.

Review: the reason the wisdom of crowds works is because each person has their own systematic error (bias) that is usually different than someone else's. It doesn't matter how inaccurate your and his responses are, just that they have different kinds of systematic errors, which thus cancel each other out. By simple analogy: I think it's small, you think it's big, so our average gets us closer to accurate.

And now you may get it: the audience abandoned their individual systematic biases, and took on the presenter's. We stopped being critical, we stopped operating around our own prejudices, and tried to think of what he wanted us to answer. We all adopted his systematic bias. He thinks "it's big," so we all picked "big."

III.

Except: when we willingly abandon our critical thinking to follow a leader, we also lose the ability to infer what the leader means, as opposed to says. This is the unintended consequences of leadership: we collectively misinterpret him the same way. There's no chance for the "wisdom of crowds" to work because we're following someone else; and without the benefit of our own critical thought and prejudices, we misunderstand him as well. "As you can see, this is very big." Wait, whoa-- did he say it's a pig? He's right, it is a pig!

It would be great if people could abandon prejudice in favor of reason; but it's far preferable for them to have their own prejudices (born out of context) than to adopt someone else's (born out of TV). And, at least in a democracy, these prejudices should balance out.

Political parties, leaders, influential books or movies-- when we let them do the thinking for us, when we adopt their position, the balancing out never happens. We do worse for ourselves. (No, this isn't a swipe at the President, I'm making a general point.)

IV .

This would be a sad enough commentary on the limitations of societies if this was the end of the story, but it wasn't. After writing this post, two or three glasses into the rum, I had a realization: none of those questions really had right answers. "What percent of bipolars experience mixed states?" can't be answered without qualification; even using DSM standards on Americans only, the answer varies widely. Not to mention what's bipolar today is often depression yesterday and god knows what tomorrow.

So not only had we followed a leader blindly into worse performance, but reinforcement from the leader when we got questions wrong ("no, no, no, this is the correct answer") means we were blinded to the fact that there weren't really any right answers.

One man had negated the wisdom of crowds, and also failed to teach us anything about nothing.

Biases and heuristics are part of how we think. We can abandon the use of a particular heuristic, but not the use of heuristics. My argument about the relative insignificance of financial bias in research isn't that I think that it is actually insignificant, but that I am more worried about the bias I cannot detect but I know is there.

Neither are heuristics necessarily bad or even wrong. Heuristics don't prevent us from thinking critically, they are actually shortcuts which are supposed to save us from our better judgment.

(from Dave Attell): "if you walk outside right now, and there's a man running naked down the street, cock flapping in the wind, you run with that man."
Huh? Why?

"Because there's some scary shit coming the other way."

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===== ====== ===== The Last Psychiatrist: The Second Story Of Echo And Narcissus

fixed it for you

Are you listening closely?

I.

This is the story you know:

"Narcissus was a man who was so in love with himself that he fell in love with his own reflection.   No one else was good enough for him. He stared into the pool, and eventually wasted away."

But that's not the whole story.

When Narcissus was born his mother, Liriope, took him to the blind seer Tiresias and asked him for a prophecy: "will he have a long life?"

Before Tiresias became a prophet he had spent seven confusing years as a woman, and made two important discoveries about women. First, that women get more pleasure from love making than men. When he told this discovery to Hera and Zeus, Hera, in a rage, struck him blind, which lead to his second discovery: not all women want to hear this.

Zeus tried to make up for his blindness by giving him the power to know the future.
So Tiresias gave Liriope his cryptic prophecy:

"He'll have a long life as long as he never knows himself."

Now what could that mean?

II.

The story you know is that Narcissus was so beautiful that everyone wanted to be with him, but he rejected them all: no, no, no, no, no, not good enough.

One rejected lover was furious and begged Nemesis, the goddess of vengeance, for retribution. "If Narcissus ever falls in love, don't let the love be returned!"

Nemesis heard the prayer and caused Narcissus to fall in love with himself: he was lead to a pool of water, and when he looked into it, he fell in love with what he saw. And what he saw wasn't real, so of course it couldn't love him back. But Narcissus sat patiently, forever, hoping that one day that beautiful person in the bottom of the pool was going to come out and love him.

You should take note of this first, easy lesson: if no one ever seems right for you, and then the one person who does seem right doesn't want you, then the problem isn't the person, the problem is you.

III.

What have you learned so far? Do you think you've understood?

You heard the story, you heard the words, but your mind unheard it and replaced it with something else. Even after I tell you this, you'll have trouble remembering it.

You think Narcissus was so in love with himself that he couldn't love anyone else. But that's not what happened, the story clearly tells it in the reverse: he never loved anyone and then he fell in love with himself. Do you see? Because he never loved anyone, he fell in love with himself.   That was Narcissus's punishment.

You thought Narcissus rejected all those people because he was in love with himself, but he rejected them all before he loved himself. Loved himself? Do you think Narcissus rejected them because he thought he was better than them? Or better looking? How would he have known he was so beautiful? He didn't even recognize his own reflection! He rejected all those people because they loved him.

IV.

You thought nemesis meant enemy, you thought it meant the person who always opposes you, the one you struggle most against. A person who is something like you, but the opposite.

But all of those explanations are your lies working to hide the truth: a nemesis is the one who makes you fall in love with yourself. Without Nemesis, there'd be no story of Narcissus. Without your nemesis, you don't have a story.

V.

Some people have tried to say that the pool Narcissus stared into was magical, that it tricked him, put a spell on him, made it impossible for him to look away. But that's wishful thinking. It would be wonderful to be able to blame the pool the way a man blames a woman for tempting him. The truth is that no magic was necessary, Nemesis had only to lead Narcissus to an ordinary pool and Narcissus would punish himself.

What did Narcissus do when he saw something beautiful in that pool? He fantasized and dreamed all the different possibilities of that person, all the things that person could be to him. He didn't stay there for years because the reflection had pretty hair. He stayed because daydreaming takes a lot of time.

And, as Ovid described about someone else:

"But his great love increases with neglect; his miserable body wastes away, wakeful with sorrows; leanness shrivels up his skin, and all his lovely features melt, as if dissolved upon the wafting winds--nothing remains except--"

except what? What do you think remains? Maybe the answer is different for everyone, but I know what you hope is the answer: anything else besides nothing.

VI.

This is a strange story. You know the main character is Narcissus, yet the title is "Echo and Narcissus."   Why do we think Echo is only a minor character? Who made Echo a minor character?

Echo was nymph with a beautiful voice, but she talked too much, so Hera cursed her to be able to only repeat the words someone else said first. "Oh!" I can hear you say. "That's where the word Echo comes from." Grow up! Do you think these are children's stories, like how the leopard got his spots? These aren't fairy tales, these are warnings.

Echo fell madly in love with Narcissus. She followed him, chased him, pined for him, but he wanted no part of her, rejecting her cruelly. Even after Narcissus died she longed for him, losing herself to that love, eventually wasting away into nothing but a voice.

He probably was right to reject her: what kind of a woman loves a man based entirely on how he looks? What kind of a woman still loves a man no matter how badly he treats her? Why would Narcissus want that kind of a person? She wasn't a woman with a beautiful voice; there was nothing else inside her except a voice.

But let's go back to the beginning of her story, no, the true beginning of the story, or do you think this is a dream that starts in the middle? If it was, we'd have to interpret it as a wish fulfillment and not as a warning.

At the beginning, Echo was watching him, hidden, but Narcissus sensed someone was there, and he was excited by it.   "Come!" he called. "Come," she could only echo, and stayed hidden, which only made him want her more. What mystery is this? He couldn't see her but he could hear her voice, and in that unfathomable voice was incarnated all the possible loves he could imagine. It helped that this mysterious woman knew just what to say to him. She was perfect for him in every way, she was the cause of his desire.

And then she came out from hiding, and he saw her.

Was she beautiful? Undoubtedly. But the moment he saw her he wretched, "Blech-- better death than should you have all of me!"

What was so wrong with her? It wasn't just that she may have been shorter or heavier than he had imagined. What was wrong was in that instant he experienced her, she stopped being anything else.

But if Echo was no longer a projection, she was still a reflection.   Echo, like all women, offered her man a peek inside his soul, all he had to do look: What kind of a man am I, that attracts this kind of woman? What kind of a man am I that attracts the kind of woman who only likes me for how I look? Despite how I treat her? What kind of a man am I that only attracts the kind of women who like me for X? Is it because there is nothing else of value inside me except X? But he was never taught to ask questions like this. In fact, he was taught never to ask questions like that. What kind of a man attracts a woman who can only echo him?   There must be a name for that kind of person, and he already had it.

If he had considered this, he might have tried to change himself, or at least recognized how similar they were.

And just as Echo wasted away to her X, a voice, he wasted away to a pretty flower-- his X.

Nothing besides remained.

VII.

How is it that centuries later, Tiresias's prophecy is still not understood?

Tiresias's prophecy was: He will have a long life, if he never knows himself.

Now, what could that mean?

Oh, he was right: Narcissus did live a long life-- though not a happy one. He spent his life alone, dreaming, and gazing into a pool, waiting to die.

But Tiresisias's prophecy seems... wrong, counter to the Greek spirit, an affront to logic; shouldn't "knowing thyself" be the highest virtue?

He will have a long life, if he never knows himself.

But it's so simple, the explanation. It's so simple that no one has ever thought of it, and the reason no one has thought of it is that it is too terrible to think about.

Forget about whether the prophecy is true. Ask instead, "what would the parents have done once they heard it?"

When Laius and Jocasta were told that Oedipus would eventually destroy them, they pinned his ankles and abandoned him in the woods, ensuring that he'd someday have cause to do it.    And so when Narcissus's parents heard the requirements for their child's long life... they would have done everything possible to ensure that he didn't know himself.

No one knows what Liriope and Cephisus did, but whatever they did, it worked: he didn't even recognize his own reflection. That's a man who doesn't know himself. That's a man who never had to look at himself from the outside.

How do you make a child know himself? You surround him with mirrors. "This is what everyone else sees when you do what you do. This is who everyone thinks you are."

You cause him to be tested: this is the kind of person you are, you are good at this but not that. This other person is better than you at this, but not better than you at that. These are the limits by which you are defined.   Narcissus was never allowed to meet real danger, glory, struggle, honor, success, failure; only artificial versions manipulated by his parents.   He was never allowed to ask, "am I a coward? Am I a fool?" To ensure his boring longevity his parents wouldn't have wanted a definite answer in either direction.

He was allowed to live in a world of speculation, of fantasy, of "someday" and "what if".   He never had to hear "too bad", "too little" and "too late."

When you want a child to become something-- you first teach him how to master his impulses, how to live with frustration. But when a temptation arose Narcissus's parents either let him have it or hid it from him so he wouldn't be tempted, so they wouldn't have to tell him no. They didn't teach him how to resist temptation, how to deal with lack. And they most certainly didn't teach him how NOT to want what he couldn't have. They didn't teach him how to want.

The result was that he stopped having desires and instead desired the feeling of desire.

Nemesis had an easy job, she only had to work backwards: show him something that didn't return his love, and he'd be hooked.

Narcissus's parents were demi-gods-- didn't they know how to raise a good son, what a proper parent needs to do? Yet they listened to a charlatan anyway. They were given meaningless information by a supposed expert and abandoned all common sense, and so created a monster who brought death to at least one person and misery to all.

VIII.

I know what you're thinking. You're worldly, you're cynical, your skeptical. You don't go for all this fate crap. You're thinking whether it is true that not loving others comes before loving only yourself--it seems backwards to you. You're thinking, what does this little girl know, really? She didn't write this, after all. (Did I?)

You're thinking whether it is true that parents create the narcissism that plagues their children for the rest of their lives. Does that match your own experiences? You're trying to remember back to your own childhood.

Am I right?

Which means you haven't learned the lesson. There you go again, thinking about yourself. Your impulse wasn't to say, "am I doing this to my kids?" or "how will I act differently?" It was to wonder about your own nature.

The moral of the story of Narcissus, told as a warning for the very people who refuse to hear it as such, is that how Narcissus came to be is irrelevant. What was important was what he did, and what he did---- was nothing.

IX.

I'm being told that I should stop here, that you've had enough. But let me tell you one more thing: there's a secret to the story. Can you guess what it is?

Close your eyes.

Imagine the scene as a large painting on the wall. There's Narcissus, sitting by the pool, head tilted downwards, arm idly twirling the water, his mind lost in daydreams. Around him are the trees, the grass, the sky. Nemesis is behind him, arms crossed, watching the punishment.

Now look closely at the expression on Nemesis's face. There's something odd there. Look closely at her eyes.

She's not actually looking at Narcissus, it only looks like she's looking at Narcissus. She's actually looking-- right back at you.

That's right, the story isn't about Narcissus, it was always about you. There never was an objective distance for you to watch from.

It was all a kind of charade.

The ancients didn't tell these stories to pass the time or teach children a lesson or tell you where the word Echo came from. Do you think we took their pop culture and made it into our literature? These stories were meditations, case studies: what do you see in them?

The secret to the story of Narcissus is that the story is the pool, it is your pool. What do you see in it? It's a reflection and a projection.

But you know the old saying, when you stare into the pool, the pool stares also into you. What does the pool see when it stares into you? How does it judge you?

Look behind you. Nemesis is there. Can you guess what your punishment will be?

Open your eyes.

You've been given a second chance.

None of this is real.

----

Audio file here.

Clarifications:

1. The Carvaggio is inverted: the reflection is gazing back at Narcissus.

2. Though the girl, age 8, is reading from a script, inflections and pacing are hers. Interesting to see how she emphasized certain passages and not others.

3. The background music of the audio file is Hymn To Nemesis, by Mesomedes (1 AD). It is one of the only surviving pieces of music from the old days. The relevance of the music is its lyrics:

Winged goddess, Nemesis, who tilts the balance of our lives, dark-eyed goddess, daughter of Justice, who curbs with iron bit the foolish brayings of mortals, and who through hatred of man's destructive arrogance drives out black envy. Beneath your relentless and trackless wheel men's fortunes turn and twist; unseen you walk beside them, and bend low the proud man's neck. Beneath your arm you measure out his life-span, and stoop to gaze into the depths of his heart, your scales held firmly in your hand. Be benevolent to us, you who dispense justice, singed goddess Nemesis, who tilts the balance of our lives.

We sing in honor of Nemesis, immortal goddess, formidable Victory with wings outspread, joint counselor with Justice, who makes no mistakes, who punishes the arrogance of men, and bears it to the depths of Hades.
Nemesis preceded even Zeus. Is she really the goddess of vengeance?

4. At the end of the audio you can here a (male) voice say, "...At least you will still look like you." This sentence does double duty. It sounds like a coda to the main theme, asking the reader to consider the implications to his own identity. But it's also the last sentence of an entirely different story, buried under the final music: The Second Story Of Medusa, which is connected to the story of Echo and Narcissus in a specific way. I'm working on a video.

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===== ====== ===== The Last Psychiatrist: The Suicide Of Bill Zeller

with respect: he was wrong

I.

I'm writing this for the other Bill Zellers.

II.

Bill Zeller, Princeton grad student and Metafilter regular, committed suicide last week, leaving behind a long suicide note that explained: "My first memories as a child are of being raped, repeatedly." The note describes growing up in a cold fundamentalist Christian household; being repeatedly molested by someone; and the parents, or at least the father, either not caring or not stopping or the molester. It's possible that the father did not condemn the molester because he had already been identified as "saved." I don't know how any mortal would know that about another mortal but I'll admit I don't fully understand "saved." I guess it means the rape charge doesn't stick.

I'll also admit that my first, reflexive, thought was that he hadn't been raped. That he made it up. The story seemed too vague, especially for a note that whose supposed purpose was to make things clearer. The language reminded me of other similar fabrications, e.g. "my first memories as a child are of being raped." First? There were no specifics mentioned; and while there was plenty of rage, there was no trace of the guilt that accompanies so many admissions of childhood abuse.

In traditional therapy these suspicions are initially irrelevant because the point is present feelings, and whether their origins are real or invented doesn't change the veracity of those feelings. But ultimately it does matter; a fabrication of molestation may signify that this is the only way they know how to verbal language storyboard the kind of pain they are feeling-- "unless I invent a trauma backstory, no one would appreciate how desperately sad I am." Or, the fabrication could signal not a pain but an undeservingness of love; the only way they think they can merit love is to be pitied, damaged. "The only time they held me lovingly is when I fell down and hurt myself." Different people will connect with either of those; you know who you are, and so I may as well say: this process is not unusual, and you are not Alone.

But looking at the comments on Metafilter, Gizmodo and other places, I was stunned at how many people I "knew"-- regulars on those sites-- admitted to being molested themselves. That guy?? That girl???? Him, too? All these people?? I began to wonder if true binary of the world wasn't men/women or rich/poor but people who had been molested and no one cared or stopped it/ people who had never been molested or someone cared and had stopped it. Even Freud's idea of the oedipal fantasy was a backpedaling: it couldn't be that all these people were actually molested, right?

But it's hard to argue with the numbers, and the numbers were overwhelming. Then came my inbox, and it was the same.   I had, as a personal prejudice, not appreciated its prevalence.   Ok. But when even the news reports blindly accepted the abuse story, I had to ask: how come no one wondered if Bill hadn't made the whole thing up?

III.

If rape was the clear motivation for his suicide, Christian Fundamentalism was the clear motivation for the rape. George Zeller, his father, is about as hard core fundamentalist as you can get, dissecting the atomic structure of something called Christian Sonship in droning recordings and labyrinthine essays, and if this man is only the assistant to the Pastor then there exists a man on this planet that I am frightened of. I don't know anything about fundamentalism, but if you pause and look at George's writings not as a religion but as an activity, what you see is George reworking and reworking the ideas over and over and repeating and repeating, nuance after nuance after microscopic nuance, until he gets them "right." But there is no right; there is only the identification of wrong. It is an obsessiveness with sterility and removing dirt that doesn't have room for outsiders-- hence his minuscule disagreements with other thinkers blown into theological catastrophes. He must always be in conflict with another's thoughts not because they're wrong but because their very presence contaminates the lattice he uses to lock down the Anxiety, yes, in the same way watching someone disturb one piece of your hoard means you have to redo the whole pile. He's hoarding religious minutiae.

George was an easy target, and if the fact of Bill's growing up in a fundamentalist home was brought up by a commenter, it was always brought up as evidence that Bill was raised by an insane man, maybe even evil.

But again, almost no one doubted he was raped. More than that: many people automatically assumed he was truthful because his parents were Christian fundamentalists, i.e. "I'm not saying all fundamentalists are child molesters but it's damn sure pretty near all of them."

And then I could see that my doubt of the rape was actually a reaction to their assumption it was true. I was reacting to their reaction. They had their prejudices, I had mine, and Bill Zeller was the excuse for an ideological battle we had already chosen sides about long before he killed himself. Ugh.

IV.

Suicide notes are unreliable; they don't convey information, they convey mood. And if you have ever been on the other wrong end of a suicide note you've probably lost part of your soul trying to decide if they were right, so let me help you: as a rule, they weren't. What they said isn't the point, it's how they said it. "I am so angry at _____." The direct object is a red herring, the subject-verb is the whole truth.

You might say it doesn't matter, ultimately, if the causes of his pain were true, only that he was in pain, and I agree; but the counter is that Bill is dead and his parents are not and now they have to live not only with the death of their son but the popular belief that they caused it. My son is dead, and he thinks I hated him.

I don't know what being molested is like; but the empty, wretched, backwardsness of your child's death, and the subsequent relentless reminder of the wrongness of reality and the impossibility of ever fixing it; the incessant scrutiny of memories, was I nice enough to him? Did I tell him I loved him? When he wanted that balloon and we were in a hurry, shouldn't I just have--

-- all that is not something anyone should have to experience. And yet that unique, infinite, unfathomable limbo is being experienced by thousands of parents a year, forever. George Zeller didn't believe in purgatory, and now he's in it, waiting for the end to come. There isn't anything else to wait for.

And I'll say something I almost dread saying: what if it is true? What if George himself raped his son repeatedly, when he was 6? Does that mean that George has lost the right to be devastated by this loss?

now what

It doesn't much matter whether he has the right or not, whether he should or not. If he did rape his son, there's a Calvinist hell awaiting him no matter how saved he thinks he is. But if he didn't, and we blame him anyway because it matches our prejudices, then that hell is waiting for us.

V.

I'd also like to address my family, if you can call them that. I despise ===== ====== ===== The Last Psychiatrist: The Supreme Court Hears Arguments That Warning Labels Should Include Things Done Correctly
A handy rule of thumb, good for reading published clinical trials and court cases is this: if you can't understand the basics in fifteen seconds, you are being lied to.

I.

Diana Levine had a migraine, and at the doctor's office a physician's assistant gave her a Phenergen injection, IV push. Unfortunately, it resulted in gangrene, and the arm had to be amputated.

Inexplicably-- and I'll explain "inexplicably" in a moment-- she chose to sue Wyeth for an inadequate warning label, specifically that it should prohibit IV push because it could lead to gangrene. As it stood, the FDA warning label only warned against IV push and gangrene.

Wyeth's response was: um, why would we prohibit the use of something that is approved by the FDA for that use? The FDA knew the risks of gangrene and IV push, and approved IV push, with the warning of gangrene.

She won the case and $6.7M. (Why? Vermont.) It was upheld in appeal: FDA standards are a minimum, and if the company sees reason to have a stronger label, they do not need new FDA approval to put one on. Wyeth should have known IV push was dangerous, and prohibited it even though the FDA approved it.

It is now being argued before the Supreme Court. The legal question is whether federal regulations preempt state requirements; i.e., if it's good enough for the Feds, should it be good enough for the states?   This is already true for medical devices. If it is, then Levine should never have been allowed to sue in state court in the first place.

So far, the Justices have bantered about whether FDA review is adequate, or if it could ever be adequate enough with such a major side effect as gangrene. Scalia observed that if the doctors at the FDA made a risk benefit analysis for IV push, a jury of laymen shouldn't be in a position to second guess it.

Justice Souter disagreed: "Wyeth could have gone back to the FDA at any time and said, either based on experience or just our rethinking of the data that we have, we think the label ought to be changed to say, 'Don't use IV push.'" Of course, that implies Wyeth thought that IV push was actually dangerous, which it didn't.

I am not a Supreme Court Justice yet, and it's likely President Obama will not choose me; but while everyone is arguing the relative dangers of IV push, a simple and important fact is being ignored: the drug went in an artery.

II.

Clearly, what happened here is that the PA made two mistakes: wrong injection; wrong administration. Why didn't she simply inject it into the muscle like everyone else on the planet does?

It's not wrong to do IV push, it happens in hospitals when an IV is already in place, but why bother to do it in an office? Let me be as clear as possible: the gangrene wasn't a result of IV push, this is not the rare case of IV push induced gangrene-- the med was not administered IV push. This is a case of medical malpractice.   The PA messed up. Exactly how is that Wyeth's fault? Oh, I know: it's their fault because they're rich and we're in Vermont. Got it.

III.

So now the discussion about warning labels actually has a deeper meaning.

When the various people argue about the "risks of IV push," they are including in that risk the risk of not doing IV push. In other words, the manufacturer is asked to be responsible for the incompetence of the clinician. Here's an example: many meds are clearly labeled "Do Not Crush." Crushing it, for example, could release all of the chemical into your body too fast. Following Levine's logic, this drug should not only carry a warning label "Do Not Crush," but the drug company should say it shouldn't be used orally at all, because someone might crush it.

Amazingly, in regular news articles I have not seen this argument anywhere. All reporting and discussion never even asks whether this is the PA's fault, and not Wyeth's. I do, however, see that every single article talks about how she is a guitarist. Is that relevant?   Actually, it is: it makes a good enough story to get 9 people to award her $6.7 million.

IV.

Leave it to the crypto-socialists at the New England Journal to recast med mal into a call to arms against corporate America.

Dr. Drazen, editor-in-chief of the NEJM, wants the court to side with Levine. He says he needs state level product liability suits, for two reasons.

1. Drazen writes in "Why Doctors Should Worry about Preemption" that product liability litigation is important as information:

Throughthe process of legal discovery, litigation may also uncoverinformation about drug toxicity that would otherwise not beknown. Preemption will thus result in drugs and devices thatare less safe and will thereby undermine a national effort toimprove patient safety.

It is beyond human capacity to comprehend how an editor-in-chief of the NEJM can argue that he needs lawsuits to get information about a drug. Does he expect lawyers to gather the required information, and laymen jurors to properly evaluate it, and then off to his desk for approval? Drazen isn't satisfied with 50 years of Phenergan use, research, and data. He needs to check with lawyers. I'll add that it simply isn't true that litigation has provided medicine with new information.

Drazen has the audiacity to cite Vioxx as an example of a drug that got FDA approval when the risks were not known, that resulted in litigation. Never mind that doctors continued to prescribe it even after the risks were known. Never mind that the NEJM, with its crack squad of peer reviewers, is the journal that let the flawed Vioxx study that minimized the risks get published in its pages.

2.

Preemption will undermine theconfidence that doctors and patients have in the safety of drugsand devices.
How confident do you want doctors to be? So confident that they don't have to worry about the difference between a vein and an artery? Not surprisingly, Drazen nowhere mentions "artery" or any negligence on the part of the PA; he doesn't even mention the name of the drug. Becuase to mention any of these real things would ruin his sophistry.

It's hard to be simultaneosly hypocritical and ignorant-- hypocrisy requires at least some awareness of reality-- but Drazen pulls it off. In pretending to be for the "consumer" by worrying that:

In strippingpatients of their right to seek redress through due processof law, preemption of common-law tort actions is not only unjustbut will also result in the reduced safety of drugs and medicaldevices for the American people.
He hides the fact that the real risk to patients-- to Levine-- isn't bad or unsafe drugs (that are 50 years old), but egregious mistakes by clinicians. Not to mention preposterously biased and uninformative medical journals.

I suspect the Supreme Court does not read this blog, but if you see them at lunch please pass this along: find for Wyeth. This case is not really about preemption, and they should make that clear. Otherwise this case will become a dinner table anecdote for Big Business, not to mention conservatives, to seethe over, so that the moment they get power back-- think Newt Gingrich in 1994-- they unleash a backlash of tort reform so dizzyingly vicious you'll beg for Pherengan IV.

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===== ====== ===== The Last Psychiatrist: The Terrible, Awful Truth About The Debt Ceiling

in football, when the game is already won, this is called "running out the clock"

The current debt crisis, the one that goes apocalyptic on August 2, the one that is front page news, all the time, is a non-issue.

You don't need to know any economics or public choice theory to know this, all you need to do is look at this pic:

Somehow this poor woman has been convinced that the essence of the problem is this deal. I can't tell if this photo is staged for a photographer standing behind her or she thinks she's testing Congressmen with giant Zener cards, but she clearly wants this to be about relationships and non-partisan debate and unity and pride. Somehow she has been convinced that what makes the U.S. different from Greece is this vote; that what confounded the Greeks was really whether or not to raise their debt ceiling. "Come on guys, just work it out!"

She doesn't appear to know how to read, or see, so whatever she thinks she knows came inevitably from the news media, the one that is now using her as a symbol of something. So with no other information you can assume the opposite and trade accordingly. (Get out by Sept 20.)

In this case, it's easy to deduce the real issue, which has no deadline. The popular phrasing of the real issue is "America's in debt, we spend more than we take in," but a more meaningful understanding of that sentence is this: we're all on the federal dole, one way or another.

Debt ceilings are accounting tricks. Whether you make the minimum monthly payment by August 2 only affects the books; as long as you make that payment you look ok on paper and so does Visa.

So it is inevitable that a deal will be struck by August 2, because that deal doesn't actually mean anything. This a is husband and wife arguing about rebalancing the household budget, each pretending they aren't going to pay the electric until he's agreed to cut back on beer and she's agreed not to be such a bitch. Whether they do it or not is irrelevant, the electric's still getting paid. The electric always gets paid, it has to, we need it for the chairs.

Not to mention that no politician wants to be remembered as the guy who made his constituency go unpaid. Public choice theory will save you by August 2, even as it wrecks you all the other times.

So when you get the temporary reprieve tomorrow-- and it is temporary-- you should do whatever you have to to get off the dole; you are getting off of it anyway.

Because one of these days we won't be able to even make the minimum monthly payment, and, keeping to the household budget analogy, in those circumstances what happens isn't that the family goes bankrupt, what happens is that the couple gets divorced. Pray on this.

II.

There's a game you should play, and it is analogous to Bloody Mary, where you and your Tiger Beat reading friends are at a slumber party, and they tell you to go into the bathroom and hold a candle and look into the mirror, and exactly at midnight if you say "Bloody Mary" three times a bloody face will appear. And you do it and it works, and you're like, "what the... did that really just happen?" Then you climb back in bed only to discover your friends put a tarantula in it.

The game is you take a major population-grabbing news story and ask, "what's going while I'm focused on this moronity?"

You can try it with Casey Anthony and get Greek austerity and Britain union protests and the commonplace use of the phrase, "the end of the euro"; but the lead story doesn't have to be frivolous for the game to be instructive. 9/11 was pretty real but if it weren't for that we might have learned how entangled the California and Federal governments were with Enron and energy suppliers in general, and the complicity of Arthur Anderson in asset price inflation and bubbles all over the world. Instead, we didn't.

Neither is it necessarily a conspiracy or a cover-up, it is simply related to the fact of finite human waking hours. Unless you're chronically running 20 hours a day, to the likely detriment of your body and silent deterioration of your sanity, just so you can do things other people don't have time for like look up the references in the introductions of research papers or watch Susan Sarandon's naked granddaughter act annoying(ly) in Joe, you're simply not going to get to everything. There's just no time, your mind can only handle one lead story a week. "But I do like to get in depth and hear both sides of the issue." That's why you subscribe to The Atlantic.

It's also fun to play "what's the lead in other countries, where this story isn't?" or "what's the lead for men/women if this story is the lead for women/men?" because it tells you what the rest of the world cares about while you're hearing both sides of the J-Lo divorce.

So let's play that out now, what's the lead story if the Debt Ceiling isn't? That one's easy:

Throw in the pic of the protestors:

and observe that in contrast to Revolution Facebook, none of those signs are in English-- and sprinkle in a little "Gunmen attack Sinai Gas Pipeline" and "Dozens Killed As Syrian Forces Storm Cities" and you have everything that would have previously driven Bush to "illegally" send the troops and Cheney to "accidentally" shoot his lawyer. The US may have the luxury of employing "watchful waiting" while Sideways Glasses Guy retweets his Time Magazine cover and plans on voting in the upcoming elections, but the guy above doesn't look like he's going to wait for anything. Especially elections.

Right or wrong I have no idea, I only know that when the Debt Ceiling Crisis is averted the Egypt problem will still be exactly the same and, unsurprisingly, so will the debt. I'm not suggesting the radicalization of the Egyptian protests are more important than our debt, I am simply reminding you that both the cause of the debt and the cause of the radicalization of the protests are more important than the "debt ceiling crisis." If anyone knows Obama's or Boehner's twitter addresses, send them a tweet.

----

3 Things Wrong With the Egyptian Revolution

The Terrible, Awful Truth About The Tax Cuts

===== ====== ===== The Last Psychiatrist: The Terrible, Awful Truth About The Tax Cuts

won't help

I. The $250,000 Question: Will Atlas Shrug? No, He's A Punk

So they're going to uncut taxes for the rich, as defined as over $250k/yr. Everyone seems to know the answer: is $250k a year rich, and why do they say they can't afford it?

Which really isn't what the arguing is about. That 4% tax increase is not on 250k but on any money above 250k, which means if you make 300k you're taxed an extra 4% on the 50k. Oh well, no ki-ran burgers for a week.

The real controversy, brought to you in HD, is about "fairness," which is defined not by the ends but by the means-- that's the only way to excite the amygdala enough to get you to tune in.   Ask John Galt why Americans will soberly and willingly part with 80% of their income if it makes sense to do so/they want an Acura, but try and take 4% and they'll gas an elementary school.

II. "I'm telling!"

Who decides fair? In the U.S., fair could mean democracy, so let's ask them: what do the majority of Americans want? They want 2% of you to pay more taxes. If you don't like it, you can move to the Caymans. Your business is already there, isn't it?

If this logic appeals to you, then you're not going to like the next part: this isn't a democracy, it's a businessocracy, which means the government isn't going to obey the will of the majority of the voters, but the majority of corporations. So: according to the gerrymandered voting of the S&P 500, what will taxes do?

Answer: they're still going up, because the corporations don't care about AGI, they care about corporate taxes, which are never going to go up, not if you want to keep your job. "Labor costs" is the answer to every political and economic question. All that other stuff about rich and poor are for ratings, to draw you into the electric coffeehouses and get you agitated, and for politicians who need a mulligan. In other words, it's for suckers. You're not a sucker, are you?

I understand that tax policies have serious effects on people, but the setting of tax policy has much less to do with revenue generation than giving voters a fairness boner. We spent $3.6T this year; these tax uncuts are going to generate $700B over ten years, assuming they don't simply get recut in four years anyway. So why are we bothering?

"The rich have to pay their fair share!" Let's look at the Adjusted Gross Income of the United States Government.

Corporate Tax: 12.9%

Individual Income Tax: 52%

Employment Tax: 32.2%

Estate Taxes: 1.1%

Excise Taxes: 1.9%

Take a moment and redistribute your fairness points.

III. Why a Tax on The Rich?

Why $250k? That number didn't come from the Bible, it is the income level that accounts for about 50% of the income tax revenue. Fortunately, it is also only about 2% of the population, so you only have to piss off 750,000 people. That's democracy. Eat it.

Why not just crush their spirits and raise their taxes 20% instead of just 4%? Because they're not stupid, they'll alter the way they get paid. W-2s become 1099s, 1099s become non-cash compensation (car, homes, etc.) And more business deductions, I for one will try to deduct rum expenses under fuel costs. The proof is in the writing.

"We won't employ contractors and nannies!" Yes you will, come on, you don't know how to entertain a 2 year old any more than you know how to put up dry wall. None of that matters anyway, not hiring another contractor pales in comparison to what Pfizer will do if Obama raises corporate taxes, or, more rigorously accurately, what Pfizer will threaten to do if Obama threatens to raise corporate taxes. Those 39 words and 4 commas may seem confusing to you, but-- and this is the point-- they are not confusing to Obama. Hence, a tax increase on the rich.

IV. The Terrible, Ugly Truth

50% of the budget goes to Social Security, Medic*, and unemployment/welfare. Add another 20% for defense, and that's pretty much the blueberry piechart. I have no ability to assign relative moralopolitical value to these things, but I can state with certainty that none of them pay for themselves. Unless DoD spending yields practical nuclear fusion or robot lawn mowers, most of that money is just a form of white collar, defense industry (and everyone they employ) welfare. And the real problem isn't today, it's over time. The baby boomers have only started to retire, and they won't be cheap.

There is a terrible, terrible, ugly truth underlying all of this, and that is that taxes don't matter to a government that can print money. The government collected $2.4T and spent $3.6T. They'll take what they get, of course, but if they had collected $2T or $3T you/they would not have noticed. The country isn't a household, it is a bank, and as long as the rest of the world believes "we're good for it," then we are. When it decides otherwise, look out. The US will go Lehman Brothers faster than you can say Bear Stearns.

V. Were We Wrong?

Some fundamental assumptions have turned out wrong. For example, we always talk about income. But we never talk about wealth. In France, they tax wealth-- literally a tax on assets. They earned 4.5 billion euros from that and France's population is 1/4th as large and not nearly as wealthy or funny.    Furthermore, every country in Europe has a VAT tax, which is quite high, sometimes over 20% on consumer products.   But a VAT is completely unAmerican because the US's entire existence is predicated on consumption. France has lots of other taxes that are probably socialist, but then again, isn't a $700B TARP fund socialist? It's as annoying.

More to the point, if the TARP fund was necessary to prevent large scale social disruption among all workers (not just the finance industry), and the 2008 crisis was simply the result of people behaving unethically/injudiciously but otherwise legally, then (a) some crisis was inevitable because you can't legislate ethics for every possible scenario, and therefore (b) US-style capitalism is only possible in the buffer of emergency sharp turns into socialism. To phrase it in terms of books everyone has heard of but no one has actually read, Disaster Capitalism relies on The Black Swan event which is ultimately a consequence of the institutional structure of capitalism (not a natural disaster) to periodically deploy the Shock Doctrine to prevent the institution from actually changing.   Long Tail that one, wildman.

VI. So Socialism Is The Answer?

To what? You don't even know what the question is.

The tax code many be complicated, all the talk on CNBC may seem technical, but our problem here is concrete, all you need are the numbers: we took in $2.4T and spent $3.6T. Anyone who attempts to discuss tax policy without including those two numbers has a whole different agenda which probably includes giving you AIDS. Run.

$2.4T in, $3.6T out. That's everything.   And don't tell me that some of our expenses are one-offs, like Katrinas or Iraqs, it is no different than blaming your budget deficit on your vacation to Disneyland. Next year you'll want to go to Disneyworld or Paris or carpetbomb Iran or tow California back out of the ocean, there's always another unexpected expense. And truth up, even if there were no unexpected expenses you wouldn't save the money, you'd spend it on drugs and shoes.

So what can be done?

Well, here are some ideas that I got from science fiction movies, along with tube cars and blinky lights on our hands telling us it's time to go:

You could raise corporate taxes by 1-3%. I understand the Pfizer result here (firing people) but the reality is they fired people anyway, so what was the point? That they won't fire more people? LABOR COSTS. The move towards globalization is happening independent of tax policy, the limiting factor isn't Pfizer's willingness to do it but Romania's willingness to go along with it.   I don't need to defend my capitalism credentials, but if the ultimate end of capitalism is to convince you you need high fructose corn syrup, the system needs some adjustment, and that adjustment is about 3%.

Or a VAT. Or a tax on wealth. Warren Buffet observed that he pays little income tax because he has little income. A 1% tax on wealth over some number could bring in a lot. Buffett has $40B, you could get $400M out of him alone, and he seems up for it. The combined net worth of the Fortune 400 is $1.2T; 1% of that is $12B a year, and here you'd only have to piss of 400 people. But, as I said, that's democracy.

Aren't these ideas anti-capitalist? It doesn't matter, they'll never happen. $2.4T in, $3.6T out. That's all that matters.

VII. The Other Ugly Truth

If you doubled income tax receipts on the rich, you still wouldn't cover the deficit.

VIII. Is $250,000 rich?

Fun fact: how much money does it take to raise kids?   To quote the great Ron Bennington: "All of it." You'll spend 10x more to send them to a 1.5x better school. Who could fault you? The alternative is school loans, which end up being a mortgage on a house you can never sell. Those time burglars are also gonna need iPads.

"Is $250,000 rich?" is a question that wants to be written, "the country needs the money, where can we get the money from?"

Which makes this next part so easy. The deficit is 10% of the GDP, a generational high. Either we cut spending or we raise our GDP, e.g. by inventing fusion engines or robot lawnmowers.

So if we're not willing to cut spending, we have to turn to business. It's that simple, because the country can't generate the revenue any other way. We rely on corporations for everything, jobs, insurance, lifestyle, products, mate selection. Say whatever you want at the CNN podium, bash the rich, shame the poor, it makes no difference. You may as well double down on the market and ride out the bump, because if it doesn't go up you'll have bigger problems than your portfolio. Pretending to reduce greenhouse gases or paying for MRIs or supporting welfare cheats or killing Muslims all costs money, if the government wants to keep doing these things and more the market has to go up. It is inevitable.

$2.4T in and $3.6T out. That's all. The reason why "is $250,000 rich?" is so hard to answer and pointless to ask is the same reason the government is in trouble. If you spend more than you take in, it doesn't matter how much money you make. You're not rich, you're doomed.

---
(pastabagel gets another writing credit)

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: The Trouble With Charlie Sheen

crazy like a fox

You want me to confirm he's bipolar? An addict? A narcissist? You don't need me for any of those things.

You can judge a man by what he says or by what he done, and this is what he's done: taken Scarface levels of drugs and slept with lots of pornstars, gotten rich, kept his hair, and not gotten fat, skinny, or AIDS. Not bad for a Wikipedia page. Mine just says, "horny/scurvy."

And he's held down a job, well, up to now anyway, and produced products that reveal absolutely no hint whatsoever of his personal behaviors. I'll give you a thousand bucks if you can find the scene in Navy Seals that looks like he was doing 7 gram rocks. (Ok, ok, the whole movie looks like...)

Of course, as fun as all that sounds-- and I admit it sounds wicked awesome-- he's also having legal, employment, and diagnostic issues, and if you put your ear up to the TV you can hear America breathing a collective sigh of relief, thank God he's falling apart, because if he wasn't crazy and there's no God then what rationalization could you possibly have for not following his lead? We want our celebrities sexy and wild but the narrative has to include a built in reason why we can't imitate them, something like divorces and cops and rehabs but definitely not genetics, lack of commitment and social retardation.   Your life sucks, but at least you have your health. Enjoy your five ounces of wine a day.

II.

"Why do you sleep with pornstars?" asks the marionette from 20/20 after weeks of texting him and visiting his home. Seriously? What answer is she waiting for? I'm not saying it's for everyone, but the question answers itself, right? It's a tautology.

The question her producers are getting her to ask in this po-mo way is, "what's it like to be able to sleep with pornstars? Got any footage?" I wish they would simply have asked it that way, but she doesn't want to appear salacious, she wants to appear concerned, indignant, superior.

In a particularly enlightening exchange, she recalls a radio interview he had done and proclaims, "one message you put out there that didn't sit well with people was that using crack socially was ok as long as you can manage it." Sheen's insanity suddenly disappears and he laughs in her face.   "Was that a joke?" she asks indignatiousnessly.   "Come on," Sheen says shaking his head, "you're a smart [sic] lady [sic], what do you think? Of course it was a joke, because it was so absurd..." Sheen may have a highly evolved brain but there was a better answer: "I do crack, and you all think it's hilarious. I say I do crack, and you all get self-righteous. I sleep with pornstars, you all want details. I say that I sleep with pornstars, and you all judge me. I may be crazy, but you-- you, you manipulative harpies, are just terrible, manipulative, harpies. Interview over. I'm going on break."

III.

An observation: Sheen went publicly insane early last week. It wasn't until this Tuesday night, after Extra and Today started showing the goddesses, that the court ordered an extraction team to medivac his kids. He's had a week of full on insanity, 20/20 had an entire crew in his house last Saturday, Radar was in there all day and no one felt obligated to rescue the children, but go on TV and publicly say you like multiple vaginas and they put your name on a database. No more interstate travel for you.

IV.

Is Charlie Sheen bipolar?

The only thing you're never supposed to do in psychiatry is offer an opinion without conducting a full psychiatric examination, they're very emphatic about this, which is weird because half your grade on the psychiatric board exam comes from diagnosing a guy in a 10 minute video clip from 1977. (Academic dishonesty spoiler alert: he has OCD.)   Thus, I will reveal here that I conducted a brief examination of Charlie Sheen, online, from my car.

I know mania when I see it, but I also know that there are a dozen reasons for mania that I can't see from the outside. The pressured grandiosity is pretty characteristic, the cause of it isn't.

But there's a much bigger story about Charlie Sheen's illness you won't see anywhere, way more important than his actual diagnosis.

Lunatic or not, Sheen makes one very solid point: CBS is not doing right by him. I don't care what he's done, Charlie Sheen is a big time actor from a Hollywood royalty pedigree, CBS made a fortune and a half on him, and now when he needs somebody in his life with a little power to step in and help him make some better decisions, they abandon him.

Forget CBS, I'll go further and say that all of Hollywood abandoned him, as they do all of their "employees." Ok, so he fires his publicist and goes on several different interview shows talking about his time as the Air Force. You know what each and every one of those shows should have done? Refused to let him on. Not aired the segments.   Whatever happened to taking care of your own? SAG, and all that? Viacom should have declared a media blackout immediately, so the public wouldn't even know he was going nuts, or at the very least not display it on purpose. There's something very cannibalistic about Hollywood, we're not surprised when they drool over an exposed breast or turn on a President, but am I the only one who finds it weird that they eat each other after years of relationships and profit? Is there any species other than soccer players that think it's ok to eat one of their own when they get ill?

Sheen made money from, and for, Hollywood, and when they couldn't make any more money off him that way they let him on Piers Morgan and made money off him that way. Is his breakdown so important 20/20 devoted an hour to it? Is it news? Doesn't this distract us from $100 oil and the fact that Egypt's Facebook Revolution is being run by the military, or is that the whole point after all?

This is CBS, this isn't some half-assed intervention by the five other waiters at the TGIFridays, CBS has limitless resources, they could spend a million dollars to hire a battalion of psychiatrists or extraordinary rendition him to Paraguay and not only not miss the money, but make a profit when he comes back fluent in Spanish. Dos y Media Hombres!   Even the Federal Government takes better care of its battle fatigued, and that's saying a lot, because they suck at it.

Whether Sheen did this to himself is irrelevant, and didn't you tell us mental illness was "no one's fault?" You don't abandon a guy when he needs you most even when he's fighting you, especially when he's fighting you. He didn't hurt you, he didn't attack you, all he did was go bananas.   You don't drag him out into the open and tie a honey sandwich around his neck and let bears eat him. "Well, we tried to help him before." You keep trying, that's your job as his "friends" or his coworkers or whatever you said you were to him a month ago, and for damn sure you don't videotape it to trade for Camel Cash or whatever currency CBS uses nowadays.

zark off

It's the old psychiatric argument, genetics or environmental? I can't ===== ====== ===== The Last Psychiatrist: The Trouble With Psychiatry-- "Not Even Wrong"

I recently read Martin Gardner's review in the New Criterion of Lee Smolin's The Trouble With Physics, and Peter Woit's Not Even Wrong: The Failure of String Theory.
I am almost finished Smolin's book, but I wanted to make a comment about Gardner's piece. Writing in the New Criterion, he should have appreciated a wider view of the books, that they speak to more than physics. They're just as much about psychiatry.

Because I suck at writing, I'm a much better speaker, I often have difficulty getting my ideas-- which are already baffling-- across to people indoctrinated in psychiatric mythology. But Gardner does a great job, so I'm simply going to quote him verbatim. I don't think he'll mind. Just substitute the word "psychiatry" anywhere you see "physics."
He sees string theory as not a theory—only a set of curious conjectures in search of a theory. True, it has great explanatory power, but a viable theory must have more than that. It must make predictions which can be falsified or confirmed.
Consider that the terms "borderline" and "narcissist" which have supposedly no predictive power, yet give you more information than the epidemiologically valid and "reliable" diagnosis "bipolar."

In a chapter on sociology, Smolin introduces the concept of “groupthink”—the tendency of groups to share an ideology. This creates a cultlike atmosphere in which those who disagree with the ideology are considered ignoramuses or fools. Most physicists tied up in the string mania, Smolin believes, have become groupthinkers, blind to the possibility that they have squandered time and energy on bizarre speculations that are leading nowhere.

The last part is key-- who among psychiatrists are willing to say, "holy crap, we just made this all up as we went along!"
The other book Gardner reviews is Not Even Wrong, the title coming from Wolfgang Pauli's quote that a theory was so ridiculously unscientific that it was "not even wrong." Quoth Gardner: "By this he meant it was so flimsy it couldn’t be confirmed or falsified."
Gardner quotes another writer (Glashow), in an indictment of why the masturbatory nature of psychiatry is detrimental to its own practitioners. Replace "string theory" with "bipolar model:"
Until string people can interpret perceived properties of the real world they simply are not doing physics. Should they be paid by universities and be permitted to pervert impressionable students? Will young Ph.D’s, whose expertise is limited to superstring theory, be employable if, and when, the string snaps?
And closing with a quote from the physicist Gerard ’t Hooft:
Actually, I would not even be prepared to call string theory a “theory” rather a “model” or not even that: just a hunch. After all, a theory should come together with instructions on how to deal with it to identify the things one wishes to describe, in our case the elementary particles, and one should, at least in principle, be able to formulate the rules for calculating the properties of these particles, and how to make new predictions for them. Imagine that I give you a chair, while explaining that the legs are still missing, and that the seat, back and armrest will perhaps be delivered soon; whatever I did give you, can I still call it a chair?
I wish I could write better, more clearly. I can't. But at least read Gardner and Smolin-- if the problem of loose science and groupthink occurs in the hardest of the sciences, physics, it most certainly occurs in psychiatry. The first step in recovery, of course, is admitting you have a problem. We may never get past this step. The second step is to stop pretending you're something you're not, stop trying to make judgments and pronouncements about which you know nothing: Wovon man nicht sprechen kann, daruber muss man schweigen.

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===== ====== ===== The Last Psychiatrist: The Truman Show Delusion Is Not Real
Interpret that any way you want.

In a news article out today, that is remarkably like the one that came out in July (my post here):

Researchers have begun documenting what they dub the "Truman syndrome," a delusion afflicting people who are convinced that their lives are secretly playing out on a reality TV show. Scientists say the disorder underscores the influence pop culture can have on mental conditions.
Other examples are thinking your life is the Matrix, an ARG, an A&E documentary.

If you break the delusion down, there are two primary characteristics: someone else, more powerful, is observing and orchestrating; and this is not your actual life, your actual life is something else.

When you phrase it like this, the delusion becomes revealed: it's regression into childhood. It doesn't discount the delusional aspect, but understanding it as a regression helps make sense of it.

By analogy, it's a conspiracy theory. Conspiracy theories provide two very important psychic comforts. First, if someone else is controlling things, then your failures are not entirely your fault. Second, it is a proxy-parent; it is comforting to know that there are powerful individuals closely following, monitoring, and influencing everything. Suddenly, there is no catastrophe that won't be averted; suddenly life has meaning, even if it isn't one you pick.

One question is to what extent one changes their own behavior to fit their role: do you play to the camera? If you're on a reality TV show, do you then also choose to dress more provocatively; talk in soundbites; make relationships the main focus of your day to day life, etc? A conscious decision to act more superficially than you would otherwise?

I'd argue that non-delusional people do this already, though much less. In tiny ways, we act like someone else is watching, we narrate or soundtrack our lives, which is fine; but the types of narration and the types of music all come from what already exists-- TV, movies, etc.

It's the Wittgenstein argument about language and thought, applied to the media.

The "medium is the message" is now the medium is the viewer. Control the medium, and you control the viewer.

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===== ====== ===== The Last Psychiatrist: The Twilight Movie Review Your Boyfriend Doesn't Want You To Read
If you're watching it, it's for you.

It's not hard to see why Twilight is popular among teen girls. The plot is a simple one-- teen girl falls in love with her teen classmate who is actually a 100 year old vampire named Edward Cullen, can they be together? It captures the thrill of first time love, when every little gesture or word always had a magnificent subtext. A caress of the face more stimulating than any orgasm. Etc.

The actress who plays the ambivalent Bella really nails the dazed, depressive vulnerability of this demo of teen girl, jerky head movements conveying emotional confusion, lips permanently parted trying to form words for feelings she can't sort out:

and she has it right down to the borderline sleeve:

Personal aside: in my life, the borderline sleeve meant two things: the girl would like me, and I would regret it.

II.

Thing is, the movie might be for teen girls, but it was watched by a lot of other people. Opening weekend, half the audience was women over 25.

Perhaps it reminded these older (?) jaded women of a more honest love, where a man was willing to devote himself entirely to the woman. All of his history and all of his development are just prelude to this love, to this relationship. And he's willing to be a man, he's going to be the strong one, he's going demand full devotion back, he's going to be jealous but never lay a hand on you; he's going to respect you, care for you, he's going to pay for all of the dinner and yes, he's going to drive, dammit.

Men are wusses. Got it.

But let this movie serve also as a warning to the women who felt it touch them: if you actually meet an Edward Cullen in real life, quickly contaminate yourself with the AIDS virus-- because it is already too late to run.

III.

Here's the basic problem with the movie vis a vis the longing women in the audience: vampires don't exist.

Duh, you say, I don't want a vampire, I want an Edward Cullen.

Actually, you don't, here's why.

Take the movie and delete any scenes-- and there aren't that many anyway-- in which Edward shows supernatural powers. You will think this an odd directoral maneuver, but I promise you it's quite revealing.

Doing this changes the movie to the story of a boy who says he's something, but the objective audience never gets to see any evidence for it. He convinces this lonely, awkward, identity-less girl that he is a vampire, and he does this not with proof but by force of personality. They then act out the rest of the same movie.

Now what's the movie about? It's about a guy manipulating a vulnerable girl.

The movie then becomes exactly what it really is already, though confused by the distraction of vampirism. She's looking for a boy to be a man for her, in the absence of a father for that role. But it's 2009-- there aren't any such men, because the existing young men weren't raised to be men, they weren't raised to track accepted roles. Because the fathers checked out on them, too, emotionally if not physically. So the best any boy can come up with-- lacking any model for identity-- is to make it up.

IV.

Edward seems always ambivalent: on the one hand he's a vampire, on the other hand he loves her. "You don't know how much I want to kill you." That's touching. He spends the first third of the movie enraged/disgusted/infatuated with her.

The explanation in the movie is that he's a vampire and she's an innocent. The explanation in real life is that she's searching for something that gives her meaning, and he's faking it. He never hated her, he was never disgusted by her. You get distracted by the vampire photo on the cover, that part is irrelevant.

Here's an example. In the early part of the movie, brooding/dangerous Edward tells Bella, "I don't think it's a good idea for us to be friends." This is supposed to show his ambivalence towards her, which some also take as a sign of his disrespect of her. Except that when he says this, at this point in the movie, they aren't actually friends. In fact, she wasn't even talking to him-- he literally ran across the parking lot, came up behind her, and opened up with that statement.

I know you weren't talking to me, but I have something to tell you

Anyone other than me ever been 15? You only do that when you want to start being friends. It's a move.   He has no ambivalence at all.

Here's another example: he (again) sneaks up behind her-- after eavesdropping, mind you-- and says all broody, "what's in Jacksonville?" and she says, "How did you find out about that?" To which he responds, even more broody, "you didn't answer my question."

Most people's response to him would be to stab him in the eye, who does this jerk think he is? And hence I can see why some audience might see him as a disrespectful misogynist. However, I'm not sure girls are aware of this, but if there are any honest men reading this blog they'll know-- it's also a move. He doesn't actually want to know what's in Jacksonville,-- he just wants to talk to her. He's not annoyed she didn't answer his question; what he wants is to convey the impression of a deep, brooding intellect who doesn't have time for "games." (Not having time for games is itself a game.)

She doesn't stab him in the eye because he knows she won't stab him in the eye. He acts like that and says that because he knows she'll respond like that. He's performing scripted dialogue, he's trying to get her to say her part that he wrote for her.

A few scenes later-- yup, sneaks up behind her again, ladies, if a guy comes up behind you and says, well, anything, then he wants to bone you-- he says some brooding/dark things and then says, "...it just means if you were smart, you'd stay away from me." Oooooh. That statement is factually correct, as it stands. But what he meant is, "I'm very mysterious, even though I'm not. Can I touch your boobs now?"

"Your mood swings are giving me whiplash." Ah, so you've been paying attention to me.

V.

Vampires don't exist, so there's little danger in 15 yo girls falling in love with them. The real danger is a 15yo boy tries to emulate Edward. You take a semi-lost 15yo boy, he looks around and perhaps he's written off the cheerleaders or the prom queen because he figures they're out of his league. He has an instinctive pull towards someone like Bella, pretty but attainable, attainable because she's semi-lost herself. And the boy says to himself, if I want to get a Bella, I guess I have to be an Edward.

In the movie Bella says to Edward, "I can see what you're trying to put off, it's to keep people away from you, it's a mask." Adolescents love to talk about masks and fronts, "that's not the real you." Because if the mask isn't the real you, then there is a real you after all. Looked at this way, the real mask-- i.e. the fake identity-- is the one the boy is consciously putting off for her to discover, the brooding artist only she can see.

All of this is typical of adolescence and therefore normal. But to you >25 year old women who liked the movie, the guy you met who seems a little Edward Culleny is a fraud, and a dangerous one.

Bella says to Edward: "this stuff doesn't exist, it isn't real." He responds: "It does in my world." Yeah. That's the problem.

VI.

Here's a part of the movie no one else seemed to have any problem with: her acceptance into Edward's family. Edward's family is "perfect"-- rich, loving artists who play baseball in the rain. Edward brings Bella home to meet them, and they welcome her warmly with no reservations. (Only one daughter objects.)

Edward's father says, "she's one of us now." Well, of course, she's not, right? On some level Bella must know she's not one of them, she's someone else, right? For example, she already has a family, remember them? and she's not a vampire.

But if her identity isn't tied to these real things-- Bella is the main character of the story, but I'll bet you don't know her last name-- then it's not a big leap for her to become one of them.

It's not hard to see how a girl like this gets lost-- her parents either don't exist or are near perfect narcissists. Her mom has decided to roam the country with her baseball player boyfriend.    On a phone call, the mom asks Bella if she has a boy in her life, and Bella says yes. Here are the next three questions, word for word, that the mother-- 2000 miles away but still parenting!-- asks Bella to best characterize the relationship: "is he a jock? Indie?... Are you being safe?" I almost expected her to ask if he voted for Obama. Are these really the most illuminating questions you ask a 17yo with her first boyfriend? If she said he was a jock, does that give the mom any real understanding into what that boy might be like, what he might mean to her? Of course not, but the boy's not real to the mother, so she can't imagine him as a person with his own existence. She can't really comprehend her own daughter's existence outside of her own.

Meanwhile, Dad is physically present in the way a quark is physically present, it's there, I guess, it does something but God only knows what.

So when a young girl's family is this hazy, it is natural that a teen might fantasize about hooking up with a more defined family-- even if it's made of vampires.

For you middle aged folks, the analogy is 80s sitcoms. There was always a friend coming over the house, and that friend was almost an extension of the family. Skippy could walk in without knocking, and mom was always happy to cook him breakfast. She counseled him, hugged him; he'd open the refrigerator like it was his house and no one shot him. I used to think, wow, doesn't Skippy's real mom mind he's never at home? But I wasn't mature enough to understand that the fact that Skippy could be away all the time meant precisely that she didn't care. The friend's real family was loose and uninvolved. So he found a new one.

In the final act, bad vampires are trying to kill Bella, so Edward brings her to his family for protection. Edward's father says, "I'll defend her like family." That sounds awesome, but here's a bit of reality: any father who so readily admits a stranger to the family at the risk of death to the other actual family members is whacked.

But that's not how a young girl might see things, because she's not just hiding out in her BF's house, she's becoming part of his family. I sympathize with this kind of magical thinking in a teen with no strong family bonds of her own, I really do, I have no beef with your fantasies. My beef is with the boy who thinks nothing of putting his family at risk in order to save his girlfriend. And even that's not as romantic as it sounds-- any guy who would do this is doing it for himself, not for the girl. He's not doing it because he doesn't want her to die; he's doing it because he doesn't want to live without her.

The movie-- and the boy-- are already showing that established family bonds can be quickly restructured to suit the passions of the boy. He's willing to alter reality and family for what he wants. What if his passions change? What if she gets fat? What chance does this kind of a relationship have long term?   Zero. Here's my point: we are raising those exact kids right now.

VII.

No one hands kids identities anymore, no one says, "this is who you are, now start acting like it." You're a man, here's what men do; your last name is X, that's who you are. Etc.

What we're teaching kids is to make it up as they go along. So they do. Or, they just morph into someone else's life.

The patterns will stay: she'll go on to have those kind of relationships, because that's the method she's learned to get that kind of passion. And he'll go on to pretend he's somebody/something-- different each time, perhaps, but each time with conviction-- because that's how he's learned you score a chick. And why would he learn anything different? His parents aren't any kind of role model in this regard. TV is death. No one reads books-- except Twilight, apparently. Even porn is infested with MILF nonsense, obviously directed towards middle aged adults. Those narcissists are so focused on their own world that they only have the imagination to fantasize about people who are already exactly like their wives; but they are too disgusted by themselves to penetrate them. Easier to fantasize that someone else is doing it.

Tell me, please, how can any teen boy respect or learn from an adult who not only bookmarks porn, but bookmarks MILF porn?

Twilight is an accurate depiction of the moves and sensations of first time love. By second time love, by age 30, there should be some maturity.

This is what it looks like when you don't.

----

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===== ====== ===== The Last Psychiatrist: The Ultimate Explanation Of Inception

the object circled in red is a distraction

(spoilers; you may want to start with this intro post first.)

I'll start at the end: the top will fall.

Take a moment. How do you feel? You're probably not satisfied, whether you agree or not. There's no relief to it, no "aha!" moment, no catharsis. That's because the top doesn't matter. You are looking at the wrong thing.

To explain how this can be known, you have to consider three metaphors that Nolan makes explicit.

A.

First, the labyrinth:

Oh, look, a maze. And Ariadne auditions for Cobb by drawing mazes, and builds model mazes; and of course her name is neck deep in the metaphor of the maze.

But then nowhere in the movie is there an actual or metaphorical maze. Arthur says they need a maze to better hide from the projections, but they don't actually do this, right? When Ariadne draws her mazes for Cobb, he rejects the square mazes and is satisfied/stumped only by the circular classical labyrinth.

And anyway, mythological Ariadne didn't construct the Minotaur's labyrinth-- Daedalus constructed it for her-- she merely showed Theseus how to get out of it. But she didn't need to: a classical labyrinth doesn't have multiple dead ends; it is a single winding path that leads either in or out.

But Theseus, like the audience, upon being shoved inside wouldn't have known the form of the labyrinth-- dead ends or single path? So to be able to find the Minotaur, he needed to know which way to go, and Daedalus told him: downwards is the only way forwards.

B.

And so it becomes clear: it's not an actual maze, it's a labyrinth, which brings us to the second metaphor: the paradoxical staircase.

A single path, that ends up back on itself.

The staircase defies geometry because it is fixed in a single perspective. If you alter that perspective, then the illusion is revealed.

Hence, Arthur and Ariadne can walk around and around the stairs passing the woman who had dropped her papers; and Arthur could sneak up on his attacker by going down the stairwell. When the perspective changed, then Ariadne and Arthur had to stop walking; then the surprised attacker could be pushed off a ledge.

But each of those times required a choice by Arthur to "see" the staircase from another perspective. Seeing it from a different perspective changed the reality.

Cobb's not trapped in a maze, he's trapped in a paradoxical staircase, covering the same ground over and over. He doesn't need Ariadne to lead him out; he needs her to clue him into another perspective.

II.

The third metaphor seems to be the wedding ring. When he's in a dream, he wears a ring; when he is in real life there is no ring. So easy? Then why did Cobb insist on using the top-- something that Mal had touched and hence defeats the purpose of a totem? Why not just look at his ring? Well, give it a try yourself:

Pay close attention to how difficult it is to see Cobb's left hand. Right hands abound; left hands are hidden in pockets, under tables, in shadows. Now that I've said it, you'll be astonished at how obviously deliberate it is that DiCaprio is hiding his left hand from us-- except at certain moments. Nolan is actively frustrating your attempts at determining whether it's a dream or not.

Why so many long gun battles and fight scenes? Can't they just dream of being at the safe or past the bad guys? No. That's how we signify (male) conflict in movies; on the way to catharsis, you have to fight.

All of this is the expression of the third metaphor, which is really the theme of the movie: resistance.

I said I only want to be shot from the right

III.

Does Inception remind you of The Matrix? The Matrix brothers wanted you to reference Baudrillard's idea of a simulated reality substituting for "real" reality. However, their execution was flawed.

The Matrix is a great movie but a poor expression of Baudrillard's ===== ====== ===== The Last Psychiatrist: The Ultimatum Game Is A Trap
Evolutionary psychology, at a newstand near you.

The Ultimatum Game:

One round only, and anonymously. Player 1 is given a sum of money to divide between himself and the unknown Player 2. Player 2 can either accept or reject the deal; no negotiation, no second chance. If Player 2 rejects the deal, no one gets anything.

What's the right division?

Answer a:

Homo economicus, the self-preserving man, would attempt to maximize his gain. For Player 1 that means offering Player 2 the least possible; for Player 2, it means accepting anything greater than zero, because anything is better than zero.

If we were all playing for monetary gain, then Player 1 would offer 99% for himself, and 1% for the other guy, because 1% is better than nothing to the other guy.

But this deal is usually rejected. In fact, anything less than less than 30% is usually rejected. So monetary gain isn't the only variable here-- people do not always choose for their best economic advantage.

Answer b:

The Economist, an excellent magazine which offers excellent analysis of complex political and economic questions, yet still manages to be on the wrong side of history every single time, explains the now accepted "evolutionary psychology" answer:

(from Darwinism: Why we are, as we are) What is curious about this game is that, in order to punish the first player for his selfishness, the second player has deliberately made himself worse off by not accepting the offer. Many evolutionary biologists feel that the sense of justice this illustrates, and the willingness of one player to punish the other, even at a cost to himself, are among the things that have allowed humans to become such a successful, collaborative species. In the small social world in which humans evolved, people dealt with the same neighbours over and over again. Punishing a cheat has desirable long-term consequences for the person doing the punishing, as well as for the wider group. In future, the cheat will either not deal with him or will do so more honestly. Evolution will favour the development of emotions that make such reactions automatic.

It takes less than a moment's thought to realize this is specious, not to mention wrong. Why is the sacrifice an example of an evolved sense of justice or fairness, and not an example of unevolved envy? Like a child who smashes the toy his brother got for Xmas?

To illustrate this, let's make the pot $10 billion. He keeps $9.99B for himself, $10M for you. Now what? Obviously, you're taking the $10M, fairness, justice and Darwin be damned.

In fact, Player 2 will likely accept $10M no matter what Player 1 gets to keep, even approaching infinity.

Evidently, what matters isn't the relative inequality of the deal, but rather how much money Player 2 gets. If he's paid enough, he doesn't care how unfair the deal actually is.

II.

The question then is: is my explanation right?

Nope.

My counterexample is a trick, and I use it to show the complete and total impossibility of interpreting behavior from hypotheticals. Hypotheticals measure identity-- who you think you are-- not who you actually are, which is your behavior.

I'm going to show you now how Player 2 would reject the $10M, consistently, as consistently as if he was offered $1 from a $100 pot.

If this experiment happened right now, in real life, the second person would more than likely refuse the $10M, because in real life there is a third person in the Game that we are not considering: the experimenter with the original pot of $10B. If such a person has $10B laying around to do this trivial experiment, let alone the money he has to repeat the experiment on other people, then $10M isn't worth anything to anybody.

Don't frown; if this was simply a hypothetical question, then none of the dollar values have any meaning at all, especially at the point of large numbers (what's the hypothetical difference between $10B and $100M?) You're simply asking people," what are your general beliefs about fairness?"   We all have a belief in our levels of bravery, honesty, greediness, which we will use to answer the questions. At some big dollar value, we'll believe that it compensates us for our sense of injustice. We're honest enough with ourselves to admit that we'd take the hypothetical $10M-- but that $10M is being compared to your ordinary economic world. But in real life, you would still refuse the deal, because you'd be living in a world of hyperinflation.

III.

What does this all mean?

It means the Ultimatum Game is not a question of behavioral economics, it is a magic trick. Magic tricks play differently to different audiences, and you cannot generalize about how humans respond to this magic trick based on how it plays in Vegas. Worse, you cannot generalize to humans based on how a group of people say they would hypothetically respond.

The Ultimatum Game yields different results in different cultures (a Mongolian group and another using ethnic Russians (Tartars and Yakuts) group both reliably offered 50/50 splits; and the even rejected offers that were in their favor (e.g. 30/70.)). Evolution wouldn't account for this. Are Mongolians a more just people? Do the Tartars have less envy? Or do they suspect that any third person who has the power to set up such a Game should not be completely trusted?

Prior to being seated, subjects were handed a consent form and asked to read it. Our
subjects were loathe to sign anything. They were guaranteed anonymity and they did not
want to leave behind any signature that they felt could be turned over to authorities.

Meanwhile, the Machiguenga people along the Peruvian Amazon, when asked by the experimenters to play "a fun game played for money" were "eager to play." They average offer was a 75/25 split, and almost no one rejected any offer, no matter how low.

The real question in the Game is whether it is worth it to you to play at all. When you reject the offer, you don't get nothing, you are not back where you started, because there is a hidden cost in the act of playing the Game. You'll never know what that cost is, and it will be different for everyone, and at different times. Playing the Game hypothetically does not in any way reflect real Game play.

War is an Ultimatum Game, and winning may be losing and losing may be winning, and individual soldiers are all playing their own version, and anyway, imagining how brave you'll be in the thick of battle does not reassure me.

There's almost an Uncertainty Principle to this Game: observing it changes the outcome. Or, more accurately, you can't know both the "real results" and the "real costs" at the same time.

Let us dispense with the belief that this Game has anything to do with evolutionary psychology, or much else.

(A follow up here.)

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===== ====== ===== The Last Psychiatrist: The Walking Dead: Not About Zombies

step 1

The Walking Dead is a show about zombies. It's a modern tale, with modern characters. They know about cell phones and Camaros, the CDC, and tanks. The show is also aware of its own artistic context, with numerous scenes referencing/honoring other movies.

Mad Max knows there's not enough time to saw the handcuff

The "suspension of disbelief" necessary for this show is that zombies could exist. Once you accept that, everything else is America 2010. Given this, why do the characters never refer to the zombies as zombies? "Walkers," "geeks," "the walking dead."

Most modern zombie stories begin from the premise that the characters have "zombie" as part of their knowledge base (e.g. Zombieland.) But somehow these characters don't ever call them zombies.

One character, fed up with the inefficiency of his camp members' zombie hunting skills, says, "you're supposed to shoot them in the head. Everyone knows that." Agreed. How did you learn that? So how come you don't know what they're called?

II.

Let's play a game, a child's game, and if the outcome of this game is a little insight that keeps you from blowing your brains out or helps you crawl out from under the bottle then it will have been worth playing. The game doesn't have to be accurate to work. Interested? The rules of this game are words, and the name of the game is the rest of your life.

So turn over the First Zombie Question Card: what is it called when something obvious to everyone else never makes it to your consciousness? Repression. Repressed material comes back distorted, sometimes unrecognizably so.

Kind of like a zombie.

III.

Sigmund Freud is mostly remembered for his work on penis and vagina, but one of his biggest contributions to society was his observations about mourning, and cocaine. He went too far with the cocaine, and not far enough with the mourning.

Observation 1: no one can conceive, that is, perceive, their own death. Allow me to vamp: the ability to do so is an indicator of substantial pathology, especially a terminal one. There's no problem conceiving of everyone else's death, but any attempt to see your own fails because it requires you-- a first person singular perspective ("I am seeing what it is like.")   An interesting experiment is to try to conceive it in second person, e.g. looking not at your wife mourning, but as your wife, through her eyes. Does that make your death seem more sad, or less? Time to rewrite the will.

Observation 2: All mourning is ambivalence. Ambi-valent, two conflicting powers: the cherishing and remembering and sadness part; and the guilt that perhaps maybe you wanted this person dead.

Wanted him dead? You're never too far from age 2, when your rage is magically powerful. At some point in your life, you thought it, and the unconscious never forgets even the briefest of hates. Sometimes the guilt over your hate has a convenient narrative: caring for a cancer-ridden, demented parent who exhausted your physical and emotional resources, and then finally(!) dies. That's going to generate a phew feelings, and they're going to cost you. All accounts must be settled at checkout.

IV.

It didn't always used to be this way.

Back in 1968, the first best zombie movie was made. How do you make a 60s zombie? You reanimate the dead. How they died doesn't matter, because the interesting part is that something had the power to reanimate them. Life after death?

Times change, and in our current time of narcissism all zombies appear through a new process: plague. That makes these zombies not so much the risen dead or the living dead as the incompletely dead. Life after life, life continuously-- even in zombie films we disavow death.

The zombie becomes the externalization of the ambivalence of mourning.

Paraphrasing from memory:

The narcissistic identification with the (loved) person becomes a substitute for love; the result is that even in the face of a conflict with the loved one, the love connection need not be abandoned. This substitute of identification instead of object-love is an important mechanism in narcissistic affections. This is a regression-- the first stage of object love is identification and is expressed ambivalently. The ego wants to incorporate this object into itself (oral stage). It wants to devour it.

Oh, I know, none of this makes sense until it happens to you. So turn over the second Zombie Card Question Card:

Apart from a scene showing a zombie eating a guy, what other scene is in all zombie movies?

A scene in which a main character confronts a loved one turned zombie. The rest of the previous zombie attacks are merely prelude to that one, specific, pivotal interaction. Quick, bolt the door, ambivalence is coming. Movies give the loved-one zombie a momentary flash of the old self-- is it remembering, is it a trap, or are you seeing what you want to see? This is the most important scene and how the living negotiate that bit of mourning determines if they'll be able to put the dead to rest, or are going to have be tied to them forever.

In The Walking Dead, there isn't just one such scene; the whole show is those scenes.    Which brings us to Observation 3:

Observation 3: zombies are uncanny. Incomprehensible, yet incomprehensibly familiar...

V.

In Episode 1, a black man and his son are hiding out in their house, the only two humans surrounded by zombies. They save the main character, Rick Grimes, who also has a kid, but Rick is white. Is that just a coincidence? Of course (not). Black is in contrast to white, which would mean-- foreshadowing-- that the black guy is going to become quite dark.

But for now, why hasn't he and his son left town? Because wife got turned, and husband couldn't bring himself to re-kill her. And so zombie wife is still shuffling up and down the driveway, coming or going, staying or leaving? He's going to stay until he can finally put her to rest, there's some unfinished mourning to do.

I miss you every single day. So this time I'm using a scope

The scope won't help. Incomplete mourning has affected his trigger finger, not his eyes, and so day in and day out he tries to (not) shoot her, repeating it over and over, working through it until he masters the material.

He can spend the rest of his life repetition compulsioning if he wants, but time marches forward and like everything else in life it comes down to a binary choice: he'll either get over her or get with her. It is inevitable.

That's why there's no sense in putting it off, and you certainly can't avoid it-- it follows you around.

That leaves the son, a small boy who isn't afforded the luxury of mourning. Children are much closer to the ambivalence of mourning, because when they (frequently) temporarily hate their parent they aren't confident of the physical limits of that hate, and if mom suddenly dies it's hard not to think you didn't have a wee bit to do with it.   Which is why the job of proper mourning falls to the surviving parent-- lead by example-- and if he's smart he'll take advantage of the 6000 years of human history and allow the rituals of mourning to naturally lead the process, that's how the unconscious works through its conflicts. Learning by doing, until it becomes second nature. (The first nature died with the parent.)

And it's never too late, if you didn't do it right the first time and have been haunted ever since, you can always go back and perform the rituals more completely. "But I won't respond to those rituals because I'm not religious." It's not up to you; you're built for ritual. So are The Walking Dead characters, who completely against everyone's and their own survival instincts decide not to burn(/deny) the bodies of their zombie-murdered friends, but bury them all in time consuming (all of it), backbreaking graves. "It's a hundred degrees out here." If the digging's harder, the mourning is easier. And that's why they (living and dead) are able to move on.

Speaking of haunting, what's one potential consequence of a parent's incomplete mourning? The kid develops a strong belief that he can see ghosts and has ESP. If you're not ready to let go, then you'll hold on tighter; and if The Walking Dead scripts according to psychological flowchart, then little Walt will be revealed as psychic. Oh, wait, that's not Walt...

VII.

In a late-r episode, Sister B gets bitten and will soon become Sister Z, but Sister A can't bring herself to terminate the process. Instead, she sits with her sister as she lays dying, then undeading.

It's a very tense scene for us not because Sister B is going to die (how sad) but because we know she's going to be pissed when she does. But it's easy for us: we're not mourning. This is the interesting part: we're not mourning sister B, we're angry at sister A-- "shoot her, idiot!" And even when Sister Z reaches an undead hand towards the mourning sister's face, Sister A doesn't fight it. We are frustrated.

She finally does discharge our anxiety right into her temple, and phew. But hold on: for most of the season I thought they were twins, I couldn't tell them apart. Nor, given their character development, was it necessary to do so. Yet in one completely "unnecessary" scene, there's a long dialogue about how Sister A went off to college and was too busy for Sister B, and how guilty she felt that she wasn't there for her-- yes, they are that much spread in age. Hmm. That would make Sister A the mother figure. Now it gets interesting. Where's Dad?

Oh, there he is. So now this isn't about losing a sister but about losing a child. The ambivalence has taken on a different character. There's no fear in this mourning, just guilt, which makes this scene NOT "if you can't save them, join them" but rather "if you can't save them, your punishment is to join them." It's no coincidence that Sister-A can't shake the guilt and opts for punitive suicide in the season finale-- only to be lead, at the last minute, through the final steps of mourning by Dad. We don't really get a sense of his pain (it must be gigantic, that was his daughter, too) because the point is her pain, and a good Dad is beside the point. That's what Dads have to be: wolfram, stoic, pulling everyone's emotional weight when it's time to do so, because if not them, then who? That doesn't make their pain easier, unfortunately, but it's what's right. Does anyone remember right? Obviously not: that's why there are zombies.

VIII.

Let's go back to how uncanny zombies are.

[If] every affect belonging to ===== ====== ===== The Last Psychiatrist: The Wisdom Of Crowds Turns Into Madness

less independent than they think

In PNAS, an article which is intuitively obvious but terrifying to see played out in science.

The "Wisdom Of Crowds" concept is that the average guesses of a crowd will be closer to the truth than a randomly selected individual guess.

The reason this works is that because the crowd has different individuals with different types of systematic error, e.g. prejudices. With more individuals, the prejudices negate each other.

The Swiss study took 144 college students and asked them a series of questions (population of Switzerland, murder rate, etc). It recorded 5 consecutive guesses, as well as the confidence for the first and last guess.

I.

The first interesting finding is that the crowd is sometimes so incredibly wrong that the mean of their responses is just... really wrong. How many assaults were there in Switzerland in 2006? 10? 100? 1000? 10000? 100000? Those are exponentially different guesses, so an arithmetic mean could be way off, factors of ten off.

In such cases, a geometric mean is much closer to the correct answer. So, point number one, when you are crowdsourcing, choose your mean/distribution appropriately.

II.

The diversity of guesses is quite large-- everyone comes to the question with their own prejudices and errors.

But merely by giving the subjects access to the previous round's guesses-- either the mean of the guesses ("aggregated information") or everyone's individual guess, the diversity disappears and everyone's guesses begin to converge.

The first round the guesses were wildly disparate, but as everyone got to see the other guesses, they converge remarkably.

Why did having the full information (all 12 people's individual guesses) seem to cause less convergence than having the mean of their guesses? It didn't, really; but also because the aggregate is only one number that you converge to; having 12 wildly disparate numbers to converge to is harder. But by the third round, it hardly mattered-- a systematic bias had been introduced into the crowd, which is ironic since it is systematic bias that the Wisdom Of Crowds is supposed to negate. Moo.

III.

People following the herd would be boring but not disastrous, except for the other finding.

Since the guesses converge, since other people are converging with you and you can see that, the confidence in these guesses goes up: a false belief of collective accuracy with no increase in actual accuracy. "It's unanimous!" Yikes.

Also remember, these people weren't being given an expert's guess to converge to, just other (regular) people's. As the authors point out, they didn't even attempt to measure group leader effects, persuasion, talking heads on TV, or twitter.

This is not a trivial problem. It isn't just saying that the beliefs converge; it is saying that since the beliefs converge along with greater confidence in their "truthfulness", it becomes more difficult for any individual to not converge as well-- and feel confident about it.

If you do manage to run from the herd you have to climb a high wall. "Can so many people be so wrong, yet so close together in their guesses? So wrong, yet so confident? Is everyone insane?"

You can imagine the social implications of a highly energized crowd, or electorate, or laity, or polity, or tax base, all converging on a "truth" of which they are supremely confident by virtue of the fact that others believe the same (which is the result of similar convergence on their part.) This is probably supercharged when you have a charismatic figurehead leading convergence, and by "charismatic figurehead" I mean media; no one person came up with this, everyone just knows it's true.

IV.

So much for the paper. Now consider the more general implications.

"Well, I'm going to be an independent thinker and not be affected by the herd and make my own educated guess." No, you won't.

The moment you have the other people's guesses, you cannot shake that information. Your "independent" guess necessarily includes that guess in some way, you can't unlearn it. Either your guess converges towards the herd, or your guess is characterized as against the herd. Either way, the herd affected your thinking in ways you don't realize. You're part of the dialectic and you didn't even want to be. That you don't want to be part of it ensures you are part of it.

The existence of the convergence of ideas, knowing that a convergence exists, either attracts further groupthink, or sets up a second groupthink in opposition to the first. Groupthink certainly reinforces one idea; and it can cause the setting up of a second large idea in opposition, but it makes a third independent idea highly unlikely (unless, again, it forms in opposition to ideas 1 or 2.)

In other words, in cases where social influence is impossible to avoid, the wisdom of crowds becomes the madness of crowds even for those who disagree with the crowd. All it takes is one idiot with a megaphone.

---

How to use your own inherent narcissism to guess more accurately

The special circumstance which causes the wisdom of crowds to fail

===== ====== ===== The Last Psychiatrist: The Woman Who Can't Forget Is Awesome Because She Can Forget
Here's a question: when someone with OCD checks the stove twenty times, why wasn't fifteen times sufficient?

Wired runs a story about The Woman Who Can't Forget, Jill Price. 43 years old, unremarkable in most ways except that she can recall every (?) event in her lifetime, including events in the world. For example, ask her when a certain plane crashed and she can tell you-- and also tell you what she was doing that day; as well as every other plane crash in the past forty years, as well as what she was doing those days, etc, etc.

It works also in reverse: give her a date and she can recall what happened to her, and what happened in the world.

She has a vivid, perfect autobiographical memory, and anything else that happened within the blast radius of her life experiences.

She's been the subject of newspaper articles, a 20/20 interview with Diane Sawyer, this Wired article. She is amazing in her skill-- no one disputes that.

However, interestingly, she has trouble with recent memory. She forgets an interview from a month ago. She cannot recall a list of ten words read to her; and, she can be tricked into remembering a word that she never heard (thread, pin, thimble but she remembers also needle.)

She was a very average student. She has not won Jeopardy.

But, she says that her memories are always running in the background of her mind, like a movie of sorts, that she can't turn off. She is an obsessive journal taker, constantly jotting down the minutiae of her life-- however, she says she rarely rereads these journals.

Wired also reports that she collects/hoards all the memorabilia of her life; her stuffed animals, old TV Guides, etc.

As I followed Price's story, I was fascinated but doubtful. I am a cognitive psychologist, and to me something didn't smell right.

The writer suspects that she doesn't have an impressive memory, per se, but rather OCD.

Price has spent her whole life ruminating on the past, constructing timelines and lists, and contemplating the connections between one February 19 and the next. Dates and memories are her constant companions, and as a result she's really good at remembering her past. End of story.
Slow down, James Randi.

It may indeed be true that she has OCD, but it is unlikely the cause of her impressive memory.

II.

First, let's answer my opening question. If someone with OCD has to check everything "seven" times or else something bad will happen, then it is the ritual that is the point, not actually getting any information from your checking.

But if someone is "neurotic" (vernacular) and has to check the stove twenty times in order to reassure himself that the stove is off, then something is not occurring between the eyeballs and the brain. He sees the stove is off, but then when he diverts his attention to something else, he does not trust himself-- he has to go back and check again. We've all had this experience to some degree-- tap into it, because there are three possibilities:

1a. you do not trust your memory of what you saw ("Did I really see it off?")

1b. you do not trust your memory of the checking ("Did I really check it, or didn't I")

2. you do not trust your attention to it (I know I looked at the stove itself and the flame was off, but perhaps I didn't pay enough attention to the knob which was turned just enough to allow a gas leak)

A few minutes reflection on these two possibilities will strongly suggest that both or either might be the explanation for the initial two or three checks. "I'm just not sure..." But why more than that? Is there a point when you feel totally satisfied? No-- you force yourself away.

3. the more you check-- the process of checking itself-- causes you to distrust your how well you performed the previous check.

Number 3 is indeed so powerful that regular (non-OCD) people can come to doubt their checks by making them check multiple times.

So a downward spiral forms: lack of confidence in memory or attention makes you check again, which in turn reduces your confidence in your attention to the check, which causes you to check again, etc, etc.

Note that the actual content of the memory is intact, e.g. accurate. If I make you check a word list, and you check it thirty times ("are you sure those are the words?") your confidence in the check will be poor (did I really look at the top five closely enough?) but your actual recall of the words will be good.

Jill Price does not lack confidence in her memories. She doesn't even need to check her journals. Going over her memories repeatedly may be what helps her remember, but it isn't OCD that's making her go over them.

III.

Lost in all the hype is an inconvenient fact: Price's brain was scanned more than two years ago, and the results--not yet published--apparently don't support the notion that she's some kind of memory goddess. Her hippocampus and prefrontal cortex are reportedly normal. The one significant aberration, according to Price--who was told about the scans by doctors who won't discuss them publicly--is that her brain resembles those of people with obsessive-compulsive disorder.

If by "resembles" he means "is as squishy as" then I'll concur. If he means something else, say, "smaller grey matter in BA6" then I dissent: the brains of people with OCD don't even resemble the brains of other people with OCD. First, anatomical differences are invisibly uninformative. Second, functional differences (e.g. fMRI) are only visible when OCD is separated by subtype (e.g. checking, hoarding, etc) but these diffferences are useful only to distinguish between groups of people you already know have OCD, not as diagnostic tests. For example, the pic below shows significant correlations to activity in (checking) OCD patients vs. controls:

But if Jill Price's fMRI was any of the red circles, what would you deduce? Anything? In order for these scans to be useful, they have to be tied to the phenomenology, and even then, they aren't worth the money.

IV.

There are some mechanistic explanations for her abilities: notable is the way she uses emotional cues (such as songs) to call up the feelings; and an intuitvely backwards calendar system to remember dates. That's for another post (someday, sigh.)

But let me leave you with a more general, social point, concerning her fame-- why we should care about her.

Oddly, the Wired writer does hit on the likely explanation for her memory:

Why were Price's abilities blown so far out of proportion? I wouldn't blame Price; she's as happy to tell what she doesn't remember as what she does. But her story has taken on a life of its own. It started with that 2006 journal article: Although the scientists knew about Price's diaries and compulsions, little in the paper speaks to the question of whether it might be personality, not memory, that makes her extraordinary.

Wrong: it is precisely her memory which makes her extraordinary, and not anything else. the mistake the writer makes is the need to find a biological explanation for her extraordinariness, as opposed to simply the result itself. Is her memory any less extraordinary because she doesn't have a gigantic hippocampus?

Also, note the conflation of "personality" with OCD. The writer is an academic psychologist, and he absolutely knows OCD isn't personality; but he uses the words interchangeably because they both mean "not related to specific memory modules in the brain."

This woman is 43, she lives with her parents, she is a school administrator, she looks like Janice from The Sopranos-- none of these things would make Wired want to write an article about her. But here's the point: if she was born with a gigantic hippocampus, then Wired wouldn't care about her then, either. And if she was born with a gigantic hoppocampus but she didn't have a superior memory-- then again, no article.

What's amazing about her is that she can do this for no good reason.

She is amazing by virtue of her personality-- i.e. adaptation to her environment. If I was an amazing marathoner by genetics-- boring. But if I was an amazing marathoner because for the first twenty years of my life I was relentlessly pursued by a puma, well, that's a story worth writing about.

She has caused to exist an amazing ability despite not having the biologic machinery one expects in these situations.

Let me put it another way: she's amazing because of what she has done, not of what she is.

And that's supposed to be the way it is for everybody.

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===== ====== ===== The Last Psychiatrist: The Women Of Lipstick Jungle Are The Same Age As Rachel From Friends
A quick observation on the premiere of Lipstick Jungle:

Has anyone noticed the age of characters in TV shows nowadays is older then it was, say, 10 years ago?

Think back to, say, Friends-- 20 somethings. Then Sex and The City-- 30 somethings. And now Lipstick Jungle, 40 somethings. "But that reflects the age of the viewers, they feature 40 year old actress because that's the age of the viewer-- or vise versa."

Agreed; but the 40 year old who is watching now was in their 20s when they watched Friends.

This isn't TV targeting a specific demographic, they are actually tracking the same people, as they age. If you're watching, it's for you.

Wait ten years-- when shows like Lipstick Jungle will be for, by, and featuring 50 year olds...

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===== ====== ===== The Last Psychiatrist: The World Is At A 52 Week Low, And The Past 10 Years Never Happened

In retrospect all things are obvious, but someone should marvel that today's close is merely 10 points different (lower) than the exact same date 10 years ago.

And you have to ask whether God has built the world as zero sum-- i.e. this is the bottom-- or as a cyclical spiral-- in which case we are destined for 800.

And the rest of the world is no different. Click "Continue" for other charts.

Oh, and pay close attention to that bottom in February 2003, and ask yourself what might have ended such a precipitous fall and coincided with the beginning of the largest bull run in history.

I'm not a tin foil hat nut, but I'll reveal something about myself: for the very first time in my life, I am scared.

Meanwhile, the dollar took a round trip, and even lost a little:

Gold caught a triple:

===== ====== ===== The Last Psychiatrist: The Worst Thing That Can Happen Is You Succeed

a market research firm that should have done a bit more market research

DO YOU REALLY BLAME SCOTT'S PARENTS FOR HIS INABILITY TO FIND A GREAT JOB AND HIS AMBIVALENCE TOWARDS THE ONE IN FRONT OF HIM?

No, just for the second. Ambivalence is learned.

WELL, WHO DO YOU BLAME FOR THE FIRST? THE MEDIA? THE GIVERNMENT?

They're all working together: overpromise, underdeliver, and apologize with aspirational goods. "Here's the lease for your new Honda. Why don't you drive it to college? For only $20k a year you can pretend you're employable."

The media designs the fantasy. They show you the cars and the clothes and the life, and your parents-- misty about their unfulfilled dreams but thankful they can put food on the table, fill in the blanks: "to get that, you need to go to school."

I TRIED TO DO IT ON MY OWN. BUT IT'S NOT SO SIMPLE AS "JUST DO IT." WHAT I NEED IS ONE GOOD BREAK. ALL I NEED IS AN OPPORTUNITY, THEN---

I frequently get requests: "I love your blog, do you ever accept submissions?"

I'm sure these people are creative and hardworking. So what do they need me for?

Working for someone else means the payoff is visible.
There's some lack of confidence in their own work, but a complete absence of confidence in the market's ability to realistically value it.   That's what happens when bad output is routinely subsidized for political ends: people will think it's all rigged. So they want an expert to appraise their output.   Immediate validation. No uncertainty, e.g. "am I really a writer?" If Random House says you are, then you are.

They're willing to work hard for someone else, while toying with their own dreams at internet cafes. ("Hey, should I open an internet cafe?")

Resistance:

resistance in a dream is symbolized by being frozen or stuck;
resistance in dating is manifested as obsessive strategizing, running scenarios, going over your audition;
resistance in pursuit of a life goal is created with endless schooling, ADHD/caffeine/marijuana, and "I just need to tighten a few things up..."

All of those are the same: "I'll do whatever it takes not to move towards success, because then I will never have failed."

SO IT'S FEAR OF FAILING AT YOUR ATTAINING YOUR GOAL?

Oh, no, this is America, no one fails in America, it's always the fault of circumstance. No, it's not fear of attaining success; it's fear of sustaining it. "Oh God, how long before they figure out I'm faking it?" That's the American horror movie.

You know how in the horror movie the killer is chasing the girl, and she trips or the car won't start? That's resistance: "I need to be punished for the earlier use of my pleasure centers-- because if I get away with it, what kind of a person am I?"

And the boyfriend wants to save her, but the door won't open or he can't get to her in time, so he has to watch her be killed. That's resistance: "If I manage to bust in there, what am I supposed to do then?"

If you become President, will you know what to do? If you get that part in a movie, will you actually be able to act? If you manage to pick up the ultrahottie at the bar, will you be able to not blow it and/or your load on the car ride home? "We can watch a couple Michael Cera movies, he's wicked.   I love your shoes.   You already have herpes, right?"

Working for someone else creates a buffer: they guided me through the first success, they'll guide me through the next one. That's what fathers are for, after all.

A DEFICIENCY OF SELF-CONFIDENCE?

How do you explain how this generation is (supposedly) the most attended to, protected, educated, well fed, anti-bullied, antibacterial, sunblocked generation in history, yet they lack self-confidence to make even easy choices like whether to chat up the brunette at the other table in the internet cafe who is equally terrified of what she's capable of? Or did you think those were separate things?

WHAT ABOUT WOMEN?

I went back to that New York Times story about Scott and his crazy corporate fantasies, and I replaced "Scott" with "Anne." You know what happened? The article became a parody. Yup. Check The Onion.

Would Anne just sit around the house waiting for the "perfect" job? Would the father and grandfather be so anxious about her future career? Would her grandfather recommend she move to Europe? Would she be allowed/allow herself to be photographed drinking iced tea?

Imagine if Anne had said this:

I am beginning to realize that refusal is going to have repercussions... My parents are subtly pointing out that beyond room and board, they are also paying other expenses for me, like my cellphone charges and the premiums on a life insurance policy.
Which term/s would the 1487 NYT commentors use most often:

slut
pig
cunt
bitch
savvy go-getter
airhead
casualty of outsourcing and illegal immigration
bimbo

There are other obstacles for women, but they do have an advantage in navigating the traditional path of college to job or grad school because they were historically told NOT to pursue that path, so they don't seem to take it for granted (though I expect that to change in another generation.) And they do not have Scott's luxury of unlimited time. Nothing trumps ambivalence like a looming deadline.

Of course, that just messes things up for Scott. Why would Scott take a job for $40k when his girlfriend, who worked just a bit harder in school, has one for $50k? "Well, because 40k+ 50k = 90k." No, 50k+40k = 90k. 40k+50k=0; they're eventually going to break up.

YOU'RE SUCH A SEXIST PIG.

Sigh, maybe, whatever. Interesting, however, that you assumed he was breaking up with her. Ha! Personal prejudice ZING!

Here's a little secret. No woman wants to be with the kind of guy who can't accept a woman who is smarter or who makes more money than him; but no woman wants a guy who is too comfortable with that, either.     Oh look, another guy in the passenger seat of his girlfriend's Honda. Betcha he controls the radio. I know, I know, it's temporary, someday he'll be buying his girl anything she wants. Too bad that if that day ever comes, it'll be a different girl.


CAN YOU REALLY BLAME PARENTS FOR PUSHING THEIR KIDS INTO THE SAFETY OF COLLEGE AND JOBS?

Of course not, I don't know any father that wouldn't advise his kid to take the job-- any job.

He is afraid of you going out on your own because he is worried about failure, of course; and he has a looming deadline of his own. "If I die, what is going to happen to this kid?" That's what all non-opiate dependent parents are thinking, all the time, at dinner, on the toilet, during masturbation, all the time. Sometimes parents even have recurrent dreams in which they die and beg God for two more hours back on Earth so they can bury a box of money in the back yard and leave a coded map, only to wake up and realize they live in an apartment.

WHAT?

Absinthe. Part of it is the normal cycle of father-son. The father looks at his 20 year old son and thinks there is no way this kid is going to make it on his own, he's not strong enough/the world's too complicated; but this is the same thing his father thought about him and all the way back to the Thetans. So the parent tries to shortcut the maturing process by getting the kid into a stable job ASAP.

The problem is that each successive generation is being raised in less gravity, so the bones are weak. The grandfather says, "my son's a bit of a wimp, but at least there's no war so he'll probably be okay." Then that kid becomes a parent and says, "my kid's an idiot, but at least he can get a college degree and that will protect him." Then that kid grows up and becomes a parent, and you know what he says? "My kid needs a bike helmet."

"How can you know what kind of a man you if you've never been in a fight?" Ed Norton asks himself in Fight Club. Well, there are other ways, but the point's solid.

Take a look at Scott's trajectory and you'll see something not at all unusual. Just as parents try to shortcut maturity with the safety of a good job, kids rebel against these shortcuts by choosing a shortcut to manhood: the military. "If I do four years of this, then my Dad will have to let me do anything I want."

This isn't to discourage joining the military; if you are brave and focused and want to pull a Wittgenstein, go; but if you are doing it because you are afraid of your Dad's disapproval of your ambivalence, then aren't there easier ways to "individuate?" Scott appears not to have thought this through very well, he quit after a year of ROTC then tries a half-assed attempt at officer candidate school and then "the sheen wore off." Oh. Has there ever been a previous instance of the words "sheen" and "Marine Corps" appearing in the same sentence?

WHY ARE YOU FOCUSING ONLY ON ENTREPRENEURS, THE CREATIVE, AND THE SELF-EMPLOYED?

Because they're worth the investment. I can't help them succeed, but sometimes the the single thing standing between trying and not trying is encouragement.

----

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: The Writers of Fool's Gold Get One Thing Right

In an otherwise unwatchable movie, a surprisingly insightful 5 seconds.

Matthew McConaughey plays a sunken treasure hunter and an idiot. The bad guy treasure hunter confronts McConaughey's partner, who is only incidentally in the movie.

"Well, well, well, if it isn't the Ukrainian sidekick."

"I don't tink of myself dat way," says the partner, whose name I don't think we ever learn. "I am dee lead character in my own story."

Right on, man. Right on.

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===== ====== ===== The Last Psychiatrist: The Wrong Lessons Of Iraq

Don't ask me about Iraq.
But I do know something about our collective response to the Iraq war, to the Bush presidency, and to our times, and it says a lot about our cultural psychology. And it helps predict the future.
It's sometimes easier to evaluate one's personality, and thus make predictions about it, by examining the defense mechanisms the person uses. In difficult situations, specific people will use a small set of specific defenses over and over; so much so that we often describe people exclusively by that defense, e.g. "she's passive aggressive."
Taking Iraq and President Bush as starting points, and examining the defense mechanisms we use to cope with both, yields the unsurprising conclusion that we are a society of narcissists.
While this discovery is familiar to readers of my blog, what might be a surprise is what this heralds for our society politically and economically. It isn't socialism, or even communism, as I had feared. It's feudalism. It's not 2007. It's 1066.
Let's begin.

Splitting
Splitting-- reducing the other person to a binary abstraction of all good or all bad, is a primitive, or regressive, defense mechanism used when the emotional level and complexity is greater than a person's capacity to interpret it. For example, once your boyfriend cheats on you, he becomes a jerk, completely. Even things he had done that were good-- like give money to the poor-- are reinterpreted in this light ("he only did that to get people to like him.") Who splits? Someone with a lot of unfocused rage and frustration, i.e. the "primitive" emotions.
Currently, our social psyche has three main targets of splitting: President Bush, terrorists, and liberals. Depending on your political bent, two of those are often conflated.
Splitting says: Bush is all bad, period. Nothing he does is good, and if it is good, it is from some malicious of selfish motivation, or an accident related to his incompetence to even be self-serving. Similarly on the other side, liberals are weak, corruptible, treasonous.
Splitting is always polar; once something is declared "all bad," an opposite is necessarily declared all good. Importantly, this isn't a comparison between the two-- he is bad, but she is better; it's perceived to be two independent, unconnected, assessments, even though to anyone else looking from the outside, they are so obviously linked. So hatred of, say, liberals is thought to be independent of your preference for Bush, but in reality it is only because you hate liberals that you like Bush. The hate comes first. And this splitting makes it nearly impossible to acknowledge any of Bush's faults.    It is a fair guess that many people voted for either Bush or Kerry not because they liked their candidate, but because they hated the other candidate.   This is the important part: that made them think that they liked their own candidate objectively. Not, "Kerry is better than Bush," but "Kerry is a great candidate." Period. That's the illusion of splitting.
(Further evidence of the relatedness of splitting: once it's gone, it's gone. Anyone voting for Kerry in 2008?)
But splitting is rarely about the target, it's a convenient heuristic to get the subject out of having to accept the complexity and totality of the other, and of their own emotions about their environment. In short, when things get heavy, it's easier to just label black and white and work from there.
Splitting is the reaction to intense anger and frustration in those people who discover themselves to be powerless.
Inherent in the act of splitting is apathy. You don't try to find a solution to the problem person, the split is the solution. It allows you not to have to deal with the other, because you've decided that the other is irredeemable.
Our apathy is everywhere. There's a war on, and, except for the TV news, you'd never know it. No one talks about it (except in brief, obvious, "knowing" soundbites, cribbed from the Daily Show.) No one protests.   The emotional focus is on Bush, not on a solution to the war, or anything else.
Here's an example: If, in the midst of no-liquids-on-airplanes Orange Alert, Cho was able to kill 30 students at Virginia Tech using two Glocks, how many students could a band of better armed jihadists kill? A quick back-of-the-envelope calculation provides a reasonable estimate: all of them. We're not ready, but, more importantly, we are not trying to be ready. Not because we don't think it could happen, in fact we're all pretty sure it is going to happen-- but because our entire emotional energy is diverted to the "all bad" other, be it Bush, liberals, or terrorists. "Terrorists-- but I thought you just said...?" Yes, because that's what splitting is, emotion directed at an abstraction of someone. We may hate "terrorists," just not those 6 terrorists right there. Real terrorists pass under our noses without even a sneer. Can anyone name one, just one, of the NJ terrorists alleged to have been planning an attack on Ft. Dix? We're too busy hating terrorists.
The problem wasn't that people thought Saddam helped the 9/11 hijackers; the problem is that no one can name any of the 9/11 hijackers. That would require work, emotional commitment, an understanding of the complexity of the Other. Much easier to say, "Saddam is evil..."
Bush is fascist and stupid, and that's it. Case closed. Now who wants pizza?

Projection (scapegoating) and some Displacement:
Placing all the blame on Bush gets us out of the hard work of introspection: why did they attack us in the first place?   What do we do when Bush leaves? What should we do now?
Blaming Bush for being an incompetent anti-Muslim warmonger purposely avoids the question of why 50% of the country was in favor of the invasion of Iraq. And some of the dissenters were against it only because they thought the costs were too high. Bush didn't attack Iraq: we all did. Right or wrong, we have been headed for a military clash with the Middle East for at least 34 years. And we are on schedule to have another in two or three years. Are we going to ask why that is, or are we going to look to CNN for an analysis of the Gulf of Tonkin?
Scapegoating also legitimizes apathy-- we can start 2009 fresh. "Sorry world-- it wasn't us, it was Bush." The trouble is, only our allies believe this. The scapegoating is really a defense; those beliefs and emotions we attribute to that "cowboy Bush" are really our own. Ask our enemies, who are certain that it's America that's the problem, not just Bush, because our enemies have a larger historical view.    Last time Iran challenged us was Carter. Was he a Halliburton warmonger? Did China/Korea prefer Truman? Putin wants Reagan back?
There isn't really an easier way to say this: that cavalier, simplistic attitude towards history; myopic beliefs which bypass logic or reason, supported only by intuition and faith; and a hatred of others who have a radically different perspective on humanity-- that's not Bush, that's us. I'm not even saying this perspective doesn't have some merit; but know thyself, yo.
Most of our enemies share a common social philosophy that, at its core, is psychic: don't trust any country where women are regularly more powerful than men; where individuals are more important than a collective; and where personal beliefs and freedoms trump historical identity. Because that means that its men are weak, its individuals are selfish, and they cannot be trusted to act in the long term interests of their own people. Rather than responding seriously to this insane worldview, with equal fervor-- and it's so easy to do it-- the country has instead chosen to release this press statement: "Bush lied."

Denial:
Since it's all Bush's fault, there isn't actually any underlying problem to deal with.
A football analogy is perfect: once you know your team isn't going to the Superbowl, the mindset and the focus changes to next season's draft, even while the current season is still on.   No more sadness, no more heartache. Focus on the future frees you from the pain of the present (though you pay lip service to it with inanities ("if the Colts are going to make it next year, they're going to have to run the ball and put some points on the board.")) Meanwhile, you're still losing this season.
We simply hold our collective breath and wait for 2008, when the "problem" (Bush) will go away.

Trouble is, the rest of the world isn't waiting, and the real problem isn't going away, it's going to get much worse.
One might make the argument that the only reason we haven't been attacked again is that everyone "knows" Bush is "insane" and would invade them. Whatever. Point is, we are in denial about much larger political problems than George Bush.

I'm only using terrorism as a convenient example, though larger political realities are in play. Chavez, Hu Jintao, Putin-- they're not reacting to Bush, they are preparing for his departure.
"If only Al Gore had won..." Then what?

Here's an example I fear no one will understand. The Iranians took 15 British soldiers hostage. I don't know what constitutes an act of war, but I figure this is pretty much it.   The soldiers surrendered without a fight (ironically, so as not to start an international incident), and then pretended to go along with the Iranians. They did the song and dance "we are bad, we are imperialists, Ahmadinejad is good, we're sorry, thanks for being so nice to us" and were eventually released.

So I'm sure those soldiers were thinking, "look, I know who I am, I know I'm not a coward, I'm not helping the Iranians, but I have to do whatever is necessary to get out of this mess." What they are saying is that they can declare who they are, and what they do has no impact on it. "I am a hero, regardless of how I act." That's the narcissist fallacy. Whatever they may think about themselves, the fact is that they did help the Iranians, and they are not heroes. But I can see that it is ego protective, I can see why they might take this perspective. There are few things in life worse than being taken hostage by the Iranians, so I understand why they would choose this type of self-deception, why they would turn to narcissism for defense. Bottom line is, I guess you can't fault them for playing along.
But here's the thing: when they returned home to Britain, they were heralded as heroes by other people. Including the British government. Based on what? They didn't actually do anything; heroism isn't simply living through a bad experience. Well, of course: based on the fact that they are heroes who had to pretend to be something else.

That's the narcissist's tautology: you are what you say you are because you said you are. What makes it an example of our collective narcissism is that we agree-- we want it to be true that they, and we, can declare an identity.
This is further evidenced by the British public's outrage-- not that they were being called heroes, but that they were allowed to sell their stories to the media. Not that they received false honor-- who cares about that nowadays?-- but that they received legitimate money.
Here's the part Americans can't get: why would Iran put them on TV when everyone is going to know it was forced? Unless you are saying that the Iranians, and only the Iranians, are so completely delusional that they actually believe the servicemen were thankful and apologetic, then this show had to appeal to some broader audience. Other people had to believe this was the real thing. Is it possible-- and I'm just asking here-- that we are the only ones who don't believe these statements were meaningful?
In other words, is it possible that our enemies judge us by our actions, regardless of intent-- and if you support Ahmadenijad on TV, then that counts-- while we retreat into the narcissists' hideout of identity-as-declared, where any actions can be disavowed as "not who we are?"

Reaction Formation: Sorry, Everybody; We're Closed
Reaction formation is an ego defense against id; when you want something that violates your identity, you shift violently to the opposite. The secretly gay man who is loudly anti-gay. It's "going overboard."
Have the interventionist Bush years taught us that we need to be more involved with the world, and work with our allies and enemies to reach a common ground? No: it's that everyone else is nuts, and the less direct contact we have with them, the better.
I find it fascinating that the key lament against Bush is not ideological, but "realist."   You might think that women's rights, civil wars, and pending genocides might be the pet issues of the Left, but increasingly Americans-- right and left-- feel that many people are simply not worth saving. That certain people aren't ready for democracy. Women's rights, while ideal, can only come after "they" (it's always they) make some necessary preliminary steps. And that, no matter what, it's never worth a ground assault if they don't really want us involved.
Not even on principle. Genocide in Darfur? Forget about sending troops to Darfur-- we don't even want to talk about Darfur. Any of the candidates mention Darfur? It's only used as a comparator: since we haven't/shouldn't send troops to Darfur where things are worse, we shouldn't have sent them to Iraq.
Isolationism is the easy defense because we can pretend no one hates us. Good luck with that.

No More Foreign Adventures
What are the political ramifications of this defensive posture? Here's an example: what happens if we are ever attacked again? It puts the nuclear option higher on the list of responses. Maybe not at the top, sure, but no way will we tolerate the costs of invading another country, no matter how well planned.
The nuclear weapons are no longer the last resort. Think about this.

Count Up Your Defenses: We're Narcissists
The primary sustenance of narcissism is control.
Why did the gods punish Prometheus?    It wasn't just stealing fire: "I gave humans the illusion they weren't doomed." You think you're in control of your destiny, because you can smoke cigarettes. Well, you're not.
Narcissism is identification without identity. It's making something up and then fighting to the death to maintain it. It's "the zeal of a convert." It's not really you, but boy oh boy don't let anyone tell you that. You'll sacrifice anything-- happiness, money, comfort-- in order to maintain control, to get people to think you are who you say you are. All that matters is people see you how you want to be seen-- even if you're really something else.
There are three ways to protect an empty identity: violence, power, and money.
Enter Feudalism
Lord, vassal and fief. The lord owns the capital; the vassal gets to use it, and profit from it, but he doesn't actually own it-- the "it" being the fief. In return for the profits, the vassal agrees to fight for the lord.
How does a man get his woman to act the way he wants, dress the way he wants, be the way he wants-- so that he can be seen the way he wants? He allows her to live in his world and profit from the splendor of it in exchange for her allegiance and deference. What if his world actually sucks? Then he just beats her.

What do we want, now? Identity-products. Things which signal to others who we want to be. IPod, Aeropostale, blogs. "This is me."   We want brands. Coke vs. Pepsi may not be relevant, but you can start a civil war by saying "Apple sucks, Microsoft is way better."
You don't realize it, but blindly identifying yourself with externalities negates your significance in the world. You're not a person, you're a block. I don't know you, but I know if you own a Mac, you voted for Kerry.   Guess what? That means that Apple carries a lot of power with Kerry. But you don't, not once you fell into this branded trap.
The joke is that Halliburton controls the government. What saves this from actually being true is that Halliburton is a public company-- anyone can buy into it. Even if they did control the government, you control them-- it nets out. And if you don't like the way they do business (or if you do,) the shareholders, or at least the biggest shareholders, can do something about it.   But if Halliburton were not public, then all that power would be concentrated in the owners. You could work for Halliburton and profit that way, but you don't share any of the power.
But now things are different. Not since the 1980s, and before that never, has there been this much M&A activity, share buybacks and privatization.   While this boosts share prices in the short term, as privateers bid up the price in a takeover, there's a huge downstream cost: the company is no longer public. You don't get to profit from it unless you work for it. Each privatized company, or the private equity firm who owns it, becomes a little lord. You want money? They demand your service. It is the opposite of owning a stock, where you demand their service. It's more than just a concentration of wealth among the few. It is also a concentration of control, and, more importantly, risk. You may not be able to profit from it, but if something goes bad, for sure you'll be asked to pay for it.
If you think Halliburton is unaccountable to the public now, imagine when it goes private. And it will go private.
Furthermore, as these companies become (more) multinational-- as they derive less of their profits from the fertile soil of the U.S. economy, they will be less beholden to its government. In fact, they will have more control over the government.

I think it's stupendous that there is an individual campaign contributions limit of $2000, equalizing the effect among rich and poor. But this actually promotes feudalism: instead of rich donors buying some access to a future official, several rich donors get together to form a PAC to influence your vote. That gets them much more power than they had as individuals. In effect, they become the lord, and the candidate the vassal. And your $2000 vote is next to worthless.
I won't be the last to make this universally horrifying observation: if Hillary Clinton wins the 2008 election, then an entire generation of people-- 24 years-- will have been ruled by either a Bush or a Clinton. Why do we keep picking them? Because they're the best? No-- because they're a brand. That saves us from thinking. And, conveniently, it gives us a scapegoat: the system is stacked against us, for them. Feudal.

Remember, the defining emotion in narcissism is rage, frustration. Collective narcissism comes from collective rage, frustration. So Marx was wrong (yes, again.) Feudalism doesn't precede capitalism, it follows inevitably, logically, after capitalism--if something, anything-- goes wrong.   In capitalism, not everyone succeeds, but everyone feels like they could. In a working capitalist model, class divisions would be fluid, people could go up and down based on their intelligence or work ethic. The mail boy could become the CEO. But if the classes become fixed, such that a mail boy could never become CEO-- only other CEOs can become CEO-- you get, well, feudalism.
When that happens-- when your future is limited, the tendency is to withdraw, get control over your local environment (family, friends, blogs, etc) and create an identity where you do have value above mail boy, even though in reality you are the mail boy. You get angry, frustrated, resentful-- at "them," the people who have more power than you.
Here's an example. On Thursday 5/10 I was listening to NPR, and the NPR interviewer said, oil companies are making huge profits, shouldn't they have to eat into those profits to lower the price? And the interviewee responded that he'd prefer the prices to be higher, or even there to be a tax, which would result in less gas consumed, which would be better for the environment, etc. And the NPR interviewer responded something like, and I'm quoting from memory, "so if you need to hit them [oil companies] in the pocket, reduced demand would be another way of doing it."
Wow. WOW. The psychological pivot point for her wasn't lower prices for the consumer, but hurting the oil companies. That's where her head was at. And she's a reporter! You see that anger, resentment, that powerlessness, disenfranchisement not in working capitalism, but in feudalism.
There's a hint of feudalism in the air already; universal healthcare, better, broader social security-- this is the lord taking responsibility for the economic well being of its people, in exchange for "service." It's not socialism because there isn't a redistribution of wealth-- the wealth and power are actually more concentrated-- it's a lease of wealth.
We are much more interested in how we will brand ourselves than in what we will do. We'll sell out our votes, our safety, our liberties and general freedoms in exchange for a safe, mostly hands-off environment where we are free to pretend to be someone. Yes to isolationism. Yes to expediency, yes to individualism. Just give me a little space. And don't tell me what I can and can't wear. My clothes are who I am.

It's not a clash of ideas, USSR vs. US; it's more visceral, personal. People hate us for us, we hate Bush for Bush, there's plenty of hate all around, so we retreat inside ourselves and our denial. We're leveraging the future for short term control of our micro-environments, selling ourselves in exchange for a 25 year lease. We want to be renters, not owners, so we don't have to fix the toilet. Meanwhile, the world trudges on.

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===== ====== ===== The Last Psychiatrist: They're Going To Get Paid No Matter What
If we reduce the costs of tests, visits, and medications to 20% of their current price, how much will overall healthcare expsenses be reduced?

I. Is the security technology of electronic healthcare records good enough?

The security problem with electronic health records isn't encryption or firewalls, it is nothing that can be fixed with better technology.

The real issue issue is the people who already have access to the records: the 10000 people who work for a university hospital system-- or the 2000 that just got laid off, looking to make a fast buck.

The real risk is if you are in a divorce proceeding and your spouse wants to use your mental health against you; or your boss/employee wants to know if you're gay; or your insignificant other wants to know etc etc. So someone makes a call to that guy they know who works there...

How could I not be tempted to look up my nurse-girlfriend's medical record... just to see? How could my brother not be tempted to ask me to look up his girlfriend at my hospital? How could janitor #7 not be tempted to ask secretary #895 to look up... for the purpose of...?

All this goes on already, and so far the records are only accessible within the system. Imagine what will happen when they are nationalized.

The analogy for electronic health records is not financial records.

If you want a working analogy for the world after electronic health records, it's facebook.

II.

I hope I don't need to point out that there's a billion-- 19 billion, actually- dollars behind EHR; about $10k/year for five years goes to the doctors, and the rest, I assume, goes to lobbyists. No, I haven't done the math, it's an estimate.

Most of the content in the record is information bias. It seems important because it exists. Do you need to know your fiancee's driving record before you finally pop the question? Of course not. But if some guy says, "I'll tell it to you for free--" would you say no? Information bias.

All medical information is redundant. That means each doctor has to find out for himself. Sure, we use them as a shortcut, but we would never act on them. To do so would be negligence. In other words: trust, but verify.

III.

Here's a hilarious story about EHR:

At the same time (that Farrah Fawcett was fighting to prove someone at UCLA was selling her medical records to the media) UCLA repeatedly asked her to donate money to the hospital for a foundation to be set up in her name.

The university went so far as to give her a prewritten letter that she could sign and fill in a dollar amount for the foundation, documents show. It also created an official-looking proposed announcement that said, "Ms. Farrah Fawcett has established a fund in the Division of Digestive Diseases with the expansive goal of facilitating prevention and diagnosis in gastrointestinal cancers."

See? They think that having a wing named after her will make up for the fact that she's dying and that one of their employees sold the records.

But a hospital is a business, they're going to get paid somehow. Anyhow.

(For a million reasons and this one, you do not want nationalized electronic health records.)

IV. EHRs Are Really About Pretending To Reduce Costs Without Actually Reducing Costs: That's Why The AMA Is Behind Them

The point of EHR is, of course, that it will "reduce costs." Oh my God.

The cost of healthcare has nothing at all to do with the value of healthcare.

If you cut the reimbursement for tests, procedures and visits, and the cost of medications, to 20% of their current cost-- you will not reduce the total spent on healthcare even one cent.

Got that? No? I will repeat it, for emphasis:

If you cut the reimbursement for tests, procedures and visits, and the cost of medications, to 20% of their current cost-- you will not reduce the total spent on healthcare even one cent.

The simple reason for this is basic economics: supply and demand. The reason people can't see this is that they have misidentified the supply and the demand. They think demand for healthcare comes from the patient, and the supply is allocated by insurers via doctors. Wrong. Doctors are both the supply and the demand.

Do you think that if reimbursement goes down, doctors will say, "ok, I guess I'm in a lower tax bracket?" They will simply ramp up their business. See more patients, order more tests, whatever. Maybe they'll buy the test machines for their office and bill the insurer for the services (e.g. an x-ray machine.)

They're not unethical, they're not trying to mismanage patients, they are just trying to survive. Why should a Goldman Sachs trader make three times more than him? They'll do whatever is necessary to help the patient, and whatever necessary to get paid.

Healthcare is a business. The business of healthcare is business.

V. What's the solution?

The solution is nuanced.

Part 1 is that you have to remove the incentive to increase the utilization of healthcare: doctors have to be salaried. I can't believe I just said that, but it is true.

The second part is the tricky one: you have to change the culture of medicine, the mindset of doctors. You have to make the natural reflex of doctors not to try to make more money, but to use less healthcare. That's nearly impossible, which means that it will fail in this generation.

So, President Obama, take the long term view: doctors become salaried starting 2020.

Face it-- doctors today are smart enough to find a way to beat the system. I am smart enough to beat the system, and it is impossible to expect me not to try to beat the system because I believe that I am not acting against the interests of society in doing it, even though I am.

But eventually I will die. The idea of a 2020 start date is that it will change the type of person who decides to become a doctor. Like academic researchers: no one goes into it for the money. I didn't go into it for the money, either, but when I got here there were opportunities to make money. How could I not take them? All of those considerations have to be removed. Then you will get a new kind of person trying to become a new kind of doctor.

Yes, this new kind will have problems of his own (apathy, institutional bias, etc.) But it will cost less. That's what you wanted, right?

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===== ====== ===== The Last Psychiatrist: This Is Baywatch

Three of the women in this picture don't exist

(An article from 1995. I edited it and added some pictures.)

I.

"Baywatch supports impossible standards that women are pressured to follow."

Everyone knows these women were selected because they are hot, that's the point. They represent ideals of a certain kind. How badly will "regular" women's self-esteem be mangled if they can't be ideals? I think they'll be fine.

Will more women want to dye their hair blonde? Get implants? Probably. Will this end up destroying America? Probably not. Will it set impossible standards for women, turn men impotent when confronted by A cups? No. Why would Baywatch do it if pornography can't?

Pamela Anderson isn't the problem. CJ is the problem. She doesn't exist.

It's conceivable that with the right supplies, you could look like Pamela Anderson. This won't destroy society. What women can't do is look and live like CJ on a lifeguard's income.

But Baywatch convinces people that there is a certain level of ordinary materialism that everyone can have. "This is what it $20,000 a year looks like."

That's what's going to destroy America.

II.

How much does it cost to be CJ? Not Pamela Anderson-- CJ. So, not how much are implants, a nose job and a personal trainer; but how much are CJ's nail appointments, and hair? How much does her (or any of the characters') makeup cost? The car lease? Her CD player and apartment in Malibu? The sofas? CJ and the gals never wear the same clothes in two shows. Never the same shoes. How much does that cost? They don't shop at Sears, right?

Baywatch, along with Beverly Hills 90210 and Melrose Place, is changing America in ways you don't notice-- precisely because you don't notice. In prior TV and movies any incongruous displays of wealth had an explanation, however cliched. Magnum PI lived off the kindness of Higgins. Rachel on Friends has rich parents.   But with rare exceptions, the characters in the new crop of 20 something TV have access to material goods way outside their pay range, but they are made so ordinary you never think to question it. We know very well how Pamela Anderson affords it. But it's made axiomatic that CJ can.

You are so busy wrestling with the sexuality of the show that you don't realize that a certain material lifestyle is being made normal.

III.

Pretend one of the shows was about interracial dating. Say, Guido gets upset that CJ could be with a Black Man whom he assumes is a thug because he listens to rap. Following a standard script, Guido gets into trouble and is saved by The Black Man, and so learns that "it's the person inside that counts" and thus there is nothing wrong with interracial dating. Ok-- let's say you disagree. Let's say you're willing to accept that not all black people are criminals, but you still have some serious reservations about letting your daughter date white guys (see?) "Oh," you think, "they're pushing a liberal agenda." You assume that Hollywood is liberal.

Maybe-- but what's more important is that you just learned that the default is that there is nothing wrong with interracial dating. The show said: this is how most of the world thinks.   If you disagree with this position, it's up to you to explain why-- not up to them to defend it.

Well, that's what the show does to leather sofas. It makes having a big TV or new shoes the obvious and default. You can protect yourself from the emotional damage of not looking like Pamela Anderson because you know she's "impossible." But you have no defense against new shoes because they're ordinary. You've incorporated a certain level of materialism into your identity and you can't ever shake it.

Baywatch will end up selling more clothes than breast implants.

IV.

Let's close our eyes and imagine, as I do frequently, peeling off CJ's red lycra one-piece. I like to stand behind her when I do it.   What do you see that's impossible? Oh, the lack of tan lines.

It seems like a trivial point, but it's not. No matter what enhancements you do to your body, after days and days on the beach tan lines are inevitable. So either she goes to a tanning studio as well, or her existence is impossible.

Pamela Anderson with no tan lines makes sense, and so you being different is explainable. But when CJ doesn't have them, then you're not going to have them either.

It's wrong to look at the Baywatch women as pornography, especially during a time when actual pornography is becoming so easy to acquire. The real pornography is the surrounding materialism, the casual display of impossible lifestyles and unattainable goods as if they are ordinary commodities. After ten hours of porn, a breast flash doesn't seem like a big deal. After ten hours of Baywatch, leasing a car doesn't, either.

In twenty years, Pamela Anderson probably won't look like she does now, but she'll still have her money. But what's going to happen to the 20 somethings who expect a certain basic level of luxury? Baywatch is popular all over the world, so this won't be limited to Americans. What's coming is a worldwide generation of future 40 year olds who will not be able to afford what they are now being conditioned to expect.

Right now the solution is easy-- debt. Because that's what everyone does to afford what they assume is basic standard of living-- e.g. cable TV. Besides, the 20 somethings always have the future-- the promise of a better job, more money. I wouldn't be surprised if in ten years it will be completely normal to be two or three annual salaries in debt.

The debts will come due, and they will come due the moment the 40 somethings realize that this is the most they will ever make; that they can't take on more debt; they can't live the lifestyle that they thought was ordinary.

I'm prepared to deal with the awesome social consequences of a generation of women with breast implants. But how can I, or anyone, live in a world where it is expected that you live well outside your means?

----

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: This Is How I Know Society Is Collapsing

From Psychiatry Vol 4. No. 2, Feb 2007 p.42:

"Second, paternal postpartum depression might be related to lower levels of estrogen."

I didn't read any further because both my eyeballs exploded.

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===== ====== ===== The Last Psychiatrist: This Is Just a Joke, Really, No, Really, It's Not Real, We're Much More Rigorous Than This, I Said It's A Joke, Okay? Let It Go!

(From Bliss at ComicsPage)

Sigh. Rispalin.   Go ahead and deny it.

It's certainly easy to make fun of it, but as a slightly different point: why do psychiatrists-- educated, intelligent, dare I say on the intellectual side of the field-- do this in the first place?
Pharmacologically, it really doesn't make sense. Ritalin is a dopamine/norepinephrine and sometimes serotonin reuptake inhibitor, as well as some degree of catecholamine releaser. Risperdal and Thorazine are tight D2 blockers. So while antipsychotics won't negate the stimulatory effects of amphetamines (different dopamine receptors, etc) the amphetamines do compete with antipsychotics for their sites, thus reducing their effect. (NB: less relevant in quickly dissociating antipsychotics (clozaril, seroquel).)
I think the reason it is done is language, i.e. the child psychiatrist can say to a parent: "I'm giving this drug for attention and concentration, and this other drug for impulsivity/aggression." Even if, pharmacologically, this can't possibly work, nor does it even make any structural sense to separate the two classes of "symptoms."
But "working" isn't the goal. Psychiatrists in this regard are asked to do something impossible: counteract a gigantic social/economic/cultural matrix of pathology with two to three medications of dubious efficacy, given to only one of the players in the matrix, i.e. the kid.
The reason they are called upon to do this herculean task is that society lacks the language and the power/commitment to handle these social ills in any other meaningful way, so it repackages them as psychiatric illnesses. In this sense, pediatric bipolar is underdiagnosed, not overdiagnosed.
So the goal isn't better treatment for the "patients"-- listen up everyone, I'm letting you in on the Trilateral Commission's big secret-- it's keeping the doctors believing the problem is medical, not social.
As long as doctors believe the problem is theirs, it will be.

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===== ====== ===== The Last Psychiatrist: This Is Not A Narcissistic Injury

I know it looks like one, but it's not. And why it's not makes every difference in predicting what will happen next.
My previous post described the modern narcissist, which is slightly different than the kind described by Kohut and others. In short, the narcissist is the main character in his own movie. Not necessarily the best, or strongest, but the main character. A narcissistic injury occurs when the narcissist is confronted with the reality that he is not the main character in his movie; the movie isn't his, and he's just one of 6 billion characters.

The worst thing that could happen to a narcissist is not that his wife cheats on him and leaves him for another man. He'll get angry, scream, stalk, etc, but this doesn't qualify as a narcissist injury because the narcissist still maintains a relationship with the woman. That it is a bad relationship is besides the point-- the point is that he and she are still linked: they are linked through arguing, restraining orders, and lawyers, but linked they are. He's still the main character in his movie; it was a romantic comedy but now it's a break-up film. But all that matters to the narcissist is that he is still the main character.

No, that's not the worst thing that can happen. The worst thing that could happen to a narcissist is that his wife cheats on him secretly and never tells him, and she doesn't act any differently towards him, so that he couldn't even tell. If she can do all that, that means she exists independently of him. He is not the main character in the movie. She has her own movie and he's not even in it. That's a narcissistic injury. That is the worst calamity that can befall the narcissist.
Any other kind of injury can produce different emotions; maybe sadness, or pain, or anger, or even apathy.   But all narcissistic injuries lead to rage. The two aren't just linked; the two are the same. The reaction may look like sadness, but it isn't: it is rage, only rage.
With every narcissistic injury is a reflexive urge towards violence. I'll say it again in case the meaning was not clear: a reflexive urge towards violence. It could be homicide, or suicide, or fire, or breaking a table-- but it is immediate and inevitable. It may be mitigated, or controlled, but the impulse is there.   The violence serves two necessary psychological functions: first, it's the natural byproduct of rage. Second, the violence perpetuates the link, the relationship, keeps him in the lead role. "That slut may have had a whole life outside me, but I will make her forever afraid of me." Or he kills himself-- not because he can't live without her, but because from now on she won't be able to live without thinking about him. See? Now it's a drama, but the movie goes on.
So if you cause a narcissist to have a narcissistic injury, get ready for a fight.
Saddam is not experiencing a narcissistic injury: he is still the main character in the movie. If he was sentenced to life in prison, to languish, forgotten, no longer relevant, no longer thought about, that would be a narcissistic injury-- then his rage would be intense, his urge towards violence massive. But who cares? There's nothing he could do.
But remaining the main character, he has accomplished the inevitable outcome of such a movie: he has become a martyr. Even in death, he is still the main character. That's why the narcissist doesn't fear death. He continues to live in the minds of others. That's narcissism.
I'm not saying executing Saddam wasn't the right thing to do, and I'm not sure I have much to add to theoretical discussions about judgment, and punishment, and the sentence of death. It doesn't matter what your political leanings are, what matters is we look at a situation that has occurred, and use whatever are our personal talents to try and predict the future.
I understand human nature, and I understand narcissism.   And I understand vengeance. Saddam was a narcissist, but this wasn't a narcissistic injury.
This was a call to arms.
We should all probably get ready.

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===== ====== ===== The Last Psychiatrist: This Is What You Wanted, Right?
Remember all those articles about bipolar needing specific treatments, and that you should never use an antidepressant?

I have a guy on Zyprexa and I add Lexapro, patient comes back the next day and says the insurance wouldn't cover Lexapro, and hands me an insurance rejection which says exactly this, punctuation included:

Clinical Review Third Party Override Required. Prescription had the following Clinical Review message(s)- "Lexapro Oral Tablet 10MG should be used with extreme caution in Bipolar Mood Disorder, which is a proxy medical condition based on the use of Zyprexa Oral Tablet 5MG." and "USE FLUOXETINE PAROXETINE SERTRALINE CITALOPRAM"

In case you're missing the beautiful irony, let me extrapolate the rejection's four points:
Didn't you psychiatrists all agree that antipsychotics are "anti-psychotics" and thus only for bipolar or psychosis? We assume you are rigorous, therefore this must be a bipolar patient.
Didn't you psychiatrists all agree antidepressants, like Lexapro, were dangerous in bipolars?
Fortunately, we at the insurance company caught your oversight before it was too late; disaster averted. No need to thank us, your silence is sufficient.
Oh, and BTW, if you ever do want to use Lexapro, don't-- please use these generics, which are ipso facto safe in bipolar, as they are generics.
It's only a matter of time before the insurance company adds:
You know, this is pretty easy; the meds do all the work, and we have to catch your mistakes anyway. So, we're going to reduce the Medicaid payment for office visits to, I don't know, $35 for an office visit. Oh, wait, we do that already! BWAHAHAHAHAHAHAHA! We'll just get the primary doc to do it.
You're going to say, no, that'll never happen. Oh yeah? Did you expect this to happen?

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===== ====== ===== The Last Psychiatrist: This Is Why Medical Care Is Expensive
The article explains:

AUSTIN, Texas - Just nine people accounted for nearly 2,700 of the emergency room visits in the Austin area during the past six years at a cost of $3 million to taxpayers and others, according to a report.
Activate populist outrage: ready, go!

The average emergency room visit costs $1,000. Hospitals and taxpayers paid the bill through government programs such as Medicare and Medicaid, Kitchen said.

After we get home from setting a few car fires, we can then ask the relevant question: what, exactly, do they mean by "cost?" Do they mean "cost," or do they mean "bill?"

I.

A frequent lament against the Obama bailout plans is that the taxpayers are footing the bill. Really? So your taxes have gone up?

Until they go up, you're not paying for nothing. The problem with the bailouts is precisely that our taxes haven't gone up: we're living on fake money again. If they had gone up, then we would be emotionally motivated to make real decisions about how we want to spend our money. In other words, once we start paying, we'll start to ask if it's worth what they billed.

II.

Healthcare may be the biggest racket in history. I don't mean it pejoratively. Quoting Charles Tilly: a racketeer is someone who creates a threat and then charges for its reduction.

This ER study can be translated: "holy crap, healthcare costs are spiraling out of control! Pay us, and we can fix it for you."

You'll see this in many forms, the most evident are this one, and electronic medical records.

Minimizing healthcare is the new healthcare.

III.

Focus on the cost: how did these patients rack up "an average of" $1000 per visit, exactly?

I once stood on a small hill and looked at an ER, and from what I could see with my B&L 10x binoculars, nothing that occurred there costed $1000. You might legitimately ask me who am I to judge what an ER visit costs; I'd submit that the only legitimate answer to what costs what is the market. But medicine isn't a market, because two parties don't agree to terms either by negotiation or by repeated bids and asks. One party makes up the terms, and the other party just pays it, or doesn't. Period.

College tuition is the same. I'm sure Harvard has some equation that spits out a $40k/year bill, but that number has no bearing on the actual costs. Case in point: if it did, they wouldn't suddenly be able to make tuition free for 20% of their students without gigantifying it for the other 80%. Perhaps tuition actually costs more than $40k. My point is that what we are asked to pay has very little to do with the actual cost.

Hospitals traditionally use the tuition model on patients: indigents can't pay, so Blue Cross is charged $300 for a guaze pad. Blue Cross knows perfectly well it is being "scammed" but they make it up from employer contributions, etc, etc, so no one complains. The only person who complains is an actual individual, with an income but no insurance, when he is asked to pay the Blue Cross rates. He doesn't realize he's being overcharged gigantically. He just knows he's about to go into bankruptcy. The problem simply is that he's caught in the healthcare racket that hospitals, the government, and private insurers have agreed to.

IV.

The article doesn't link the actual study, because the actual study is not available. Solid. I did find last year's study, which explained precisely how they arrived at the costs:

Calculating Estimated Costs

Because no cost data exist for charity care provided by ICC members, a method of estimating costs was selected based on a review of healthcare literature. The method chosen for this study, Diagnosis Cost Groups (DCG), uses patient diagnoses to estimate each patient's health status, or predicted need for healthcare utilization. The DCG models used all diagnoses from the one-year study period along with demographic patient data to calculate a measure of the expected costliness of each patient relative to the average Medicaid patient. This measure, called relative risk (RR), was then converted into annual patient cost estimates through the use of a cost multiplier. Once cost estimates were established, the RR scores were rescaled to have a mean of 1.0 by dividing each RR score by the mean RR score. The rescaled RR scores show how costly a patient is relative to the rest of the study population.

If you read something in a medical study that is confusing, it almost always means you are about to be misled. I'll translate this:

If the average Medicaid patient costs X, then each disease is weighted as a multiple of X. e.g. a diabetic patient "costs" 2X, according to the DCG.

It should be obvious that this number could as easily by 9X or .1X, or anything at all. Leave that aside.

See how hypertension costs $30M to treat hypertension in the population? It doesn't. It costs $30M to treat all patients with hypertension and anything else they have. It doesn't cost $56M to treat pregnant hypertensives.

I'm sure this can easily be spun to mean "please give us more money so we can treat depression, because look how much it's costing you guys!" but it doesn't mean it costs $20M to treat depression, only that people with depression-- and all their other infirmities-- accounted for $20M. Of course, that's $20M in estimated costs, estimated by simply multiplying some hypothetical figure by 3.9.

Also note that even if we had the data for what each and every single patient spent that year, we'd still have no figure remotely close to the truth. $900 for an MRI? Please explain.

I had once read on the internet that price fixing was illegal, but I guess not.

V.

All of this comes down to the central issue in healthcare reform: reducing costs. Absolutely no one is seriously interested in doing this. They may be serious about reducing the billings to Medicare; or reducing the flow of money to Pharma-- all of which maybe legitimate goals. But these reductions in billings will inevitably be offset by increases elsewhere, because no one wants to get to the cost of anything. Aetna still needs to eat.

Aetna won't bother to cover anyone, and doctors wouldn't bother to treat anyone, if medicine billed what it costed. Unless a hospital can bill someone $300 for a guaze pad, it's going to close down and turn into a Dunkin Donuts.

Nor is the government interested in closing down Aetna or doctors; Medicare is social welfare program for medical providers, just as Medicaid is a social welfare program for the poor. The government will keep its books open, and pay the populace just enough to keep them from rioting.

Before you yell at me, understand why we're in this mess in the first place: because medicine is believed to cost the sum total of the physical capital-- procedures, guaze pads, and not the intellectual capital. (Lawyers have it the other way.) The solution to this is to value medical care as the actual cost (not billing) plus some reasonable amount for the intellectual thought that may go into it (assuming doctors agree to put some thought into it.) I'll add that $60 per patient from medicare is probably not going to be enough.

Certainly I am for "redirecting" the "frequent fliers." No argument from me that we spend money needlessly, that there aren't better alternatives. But don't be fooled for a second that anyone wants to implement the actual alternatives. We're going to spend money on electronic medical records.

Put another way: do you think those Austin area ERs will ultimately bill $3M less if they sent those 9 patients to Neptune? Let alone if they got Aetna?

===== ====== ===== The Last Psychiatrist: This Is Why The American Dream Is Out Of Reach

That's 90% of the answer right there

Scott, a 24 year old dean's list college grad, is smart but unemployed. According to the New York Times, in five months, only one job has given him an offer: $40k as an insurance claims adjuster.

Scott said no, because

Rather than waste early years in dead-end work, he reasoned, he would hold out for a corporate position that would draw on his college training and put him, as he sees it, on the bottom rungs of a career ladder.
Now, the easy way to go here would be to call Scott an idiot for giving up a $40k/yr job in the midst of a recession. However, a) the recession ended last year; b) 1487 NYT commenters did the heavy lifting. No, I'm going this way:

"The conversation I'm going to have with my parents now that I've turned down this job is more of a concern to me than turning down the job," he said.
He was braced for the conversation with his father in particular. While Scott Nicholson viewed the Hanover job as likely to stunt his career, David Nicholson, 57, accustomed to better times and easier mobility, viewed it as an opportunity.
A long time ago, before psychiatry and rum, I seriously considered a job in intelligence. Among other things I had some Russian, and I knew another guy who was fluent in Russian and was actively being recruited by the CIA.    He decided not to do it because... his Dad wouldn't let him. At that time it struck me as curious that you'd be more worried about your dad than the Russians, but I have since understood: we were living in a time where there was no right and wrong, no objective truths, all things were relative except the inviolable Law of Growing Up American: go to college, then get a job. Your dad's sole purpose was to make sure you followed that rule.   If you raped a murder victim then your Dad would get you a good lawyer, but if you showed any proclivity towards anything other than a future 9 to 5 in a field he understood, it was your ass.

I'll grant you up front that Scott probably suffers from a mixture of ennui and myopia and absolutely no chance of STDs, who apparently feels neither shame in nor fear about sabotaging his job prospects by appearing in these photographs, to the fury of every other American who sees them:

This is a guy whose entire job search is conducted online in the mornings. Anybody want to hire this go-getter?

But for me, you have to start at what's known to be a fact: this is the New York Times.
You almost have to wonder why they would photograph him in this way if they weren't trying to sabotage him, trying to make him look like a privileged (white) out of touch jerk, just to bring out the populist backlinks. This is the NYT after all, where playing to the lowest common populist denominator is the next best thing to running a Page 3 Girls. "Do you mind pouring a Gatorade? We're trying to show how the millennials won't let their unemployment stand in the way of their thirst. Sigh, iced tea will do."

So I'll grant you that Scott is responsible for his own plight in the way that everyone carries the burden of their own choices, but Scott wasn't born in a vacuum, he was born to parents, parents who think this:

"I view what is happening to Scott with dismay," said the grandfather, ===== ====== ===== The Last Psychiatrist: This Man Killed His Family And He Doesn't Know Why

I guess I didn't want any witnesses

Christian Longo was a "successful businessman" who fell on bad times/spent too much money. Too ashamed to admit to his wife he was failing, he tried credit and then theft/forgery/counterfeiting to maintain the image. When he knew the cops were on to him, he did the obvious thing: he strangled his wife while she was on top of him during sex; then strangled his 2 year old daughter who was sleeping on the floor beside their bed; stuffed their bodies in suitcases; then put his other two sleeping kids into their car seats and drove them to a bridge, tied rocks to their feet, and threw them in the river. Then he went to Cancun.

He had the kind of time in Cancun you'd expect: drinking beer, smoking pot, and pretending to be a New York Times reporter (he had always wanted to be one), and having sex with a girl who wanted to be a photojournalist who thought he needed one for his story. Within a month he was caught.

Coincidentally, (or not, depending on your belief in synchronicity;) (or not, depending on whether you believe anything Christian Longo says;) the reporter he was impersonating was simultaneously being outed as having faked an article in the NYT.

Longo was convicted and sentenced to sitting on death row for the rest of his life. But he never confessed. Longo decided he would only tell his story-- the real story, of course-- to Michael Finkel, the reporter he had impersonated.

II.

It's not spoiling much to tell you that Longo is a classic narcissist, but it's worthwhile to go through the examples:

Longo was not a violent or mean person:

In fact, I could not unearth a single violent incident in Longo's life before the murders, apart from a minor scuffle his freshman year of high school. I looked everywhere; I spoke with everyone I could. I didn't even find an occasion when he lost his temper, when he so much as raised his voice. He hardly swore; he never fought with his brother. A woman who attended his church said she used to tell her friends, "I wish my husband could be more like Chris Longo."
But past performance is not indicative of future results because he's never been tested: he's never had a narcissistic injury, wherein you are discovered to be not what you said you were. He thought of himself as-- he wanted people to believe that-- he was a successful, rich, businessman. But the business ran out of money, the debts piled up; so he counterfeited and forged, not to cover expenses but to keep up appearances.

And you can't admit that you've been deceiving your wife for years, that in reality she's married a loser and a liar and a thief... You're trapped.
Trapped? If he cared about money he would have stolen more of it; maybe even killed a couple of people to get their money. No. If he cared about his freedom he could have abandoned his family and fled the country. No. If he felt guilty about what he had done he could have found Jesus or simply killed himself.   No. The thing he cared about more than anything else was his identity, and the ones who reflected that identity back to him were his family. They had to go.

Probably, you don't understand how killing people you love so much protects your identity: aren't you now going to be exposed as a murderer? But if you kill your family, then no matter what else happens to you it doesn't matter, because they will never know. You did them a favor: they don't have to live with the pain of knowing you are a fraud.

III.

Even a narcissist is going to feel some remorse when he kills his family, right? It's not like he didn't love them:

When thinking back about times in life where my heart was squeezed in my throat, nothing hurt more than when Sadie fell off the swing that I was pushing her on. To see tears fall from your child's face that you are the direct cause of was more painful than anything that I could remember. It's still painful. How could I be so horrible & still have that sort of pain?
Nope. Those are reflex emotions, the kind you feel watching a romantic comedy or a porn or Beaches.

Also, he noted, as further refutation of his psychopathy, "I got choked up during E.T. & Titanic."
That's right, he said choked.

But his reaction to the photo [of his smiling kids] disturbed him. "I'm not really feeling what everyone else feel's," he wrote, tossing in, as he often does, an extra apostrophe. "What should be most difficult to stomach is what I've done [the murders], yet somehow that part is still palatable."
Narcissists don't feel guilt. Only shame.

IV.

Guilt implies an internal sense of right and wrong. Whether it originates from your religion or your parents or the penal code or Star Wars isn't relevant, only that external rules are then internalized, and you then build an identity around them. So that when you violate them and there is no way anyone noticed, it still gnaws at you because it conflicts with your ego, who you are. Id exists from birth, so superego has to precede ego.

Shame comes not from the action but from the exposure. You wouldn't say you were ashamed unless you have been observed, caught.   Shame is a conflict with reality: I think I'm this kind of a person, but now this other guy has external evidence that I'm not.

A narcissist can't feel guilt because, while he admits to external rules (religion, ethics, etc) those rules are always secondary to his identity. As long as the identity is intact, you didn't do anything really wrong. There's no internal conflict with your sense of self because your identity has one superseding rule: self preservation. You will sacrifice anything, including your life, to preserve that identity. That's why your boyfriend killed himself to get (back at) you.

If Christian Longo had been arrested in Cancun for forging checks, he would have felt worse about that than about killing his family. And he will always feel worse about anything that exposes him than about killing his family.

Longo's facade in prison is the same as it was in the outside world: a ===== ====== ===== The Last Psychiatrist: This Needs To Be Explained

145000 unique visitors may not seem like a lot to those in the porn industry, but it's a lot for me, and especially for a "throwaway post" like the one on Halloween.

Getting on Digg and the front page of reddit certainly is the cause of this, but not the explanation. The post got over 200 comments, not counting what my spam filter destroyed; more importantly, the post went to places like metafilter, where it had over 170 comments-- more than any other post that week.

Why?

About half of the people didn't like the article at all. A lot said it was badly written. (I know.) A lot disagreed with what they thought were my points-- the same points that made the other half like the post.

There were four elements of the post that received the most attention.
Are violent films bad for kids? Very polarized debate. Interestingly, the debate was always personal and negative: "watching horror movies didn't affect me." No one asked whether currently violent people had watched horror movies as a kid, and if it had an impact. And no one suggested they'd be okay with taking their kid to one.
What is "torture porn?" Are horror movies really porn? To call it porn implies something-- what is the nature of that implication?
I was surprised by the number of people whose main criticism was the photo of the stroller-- that it wasn't scary. "It's just a stupid stroller!" That is an example of concrete thinking, and I'd bet that those people like Halloween, Hotel, etc, but are not touched by them (i.e. they go to sleep with the lights off no problem.) I'm not criticizing, just profiling a preference set.
Why did I refer to the parents as "obese" and "white?" Is that really relevant?
I posted a comment on metafilter that is worth repeating/rephrasing here:
1. I suck at writing. Some of the criticisms of my points are really the result of this. Not an excuse, just an explanation. If I wrote better, I think there would have been less disagreement.
2. The point of the last sentence was NOT that horror movies make kids into ADHD serial killers-- that's up for debate. My point was that those/these kids are growing up in a family/environment where obviously there are so many negatives-- taking them to Halloween is simply an example-- that for psychiatry to be focused on utter nonsense-- food additives and ADHD-- misses the whole context of the "ADHD" child. Psychiatry does this a lot: it focuses on the trivial because it's the only thing it can affect. But in doing this, it creates the social policy story that these minor issues are the causative, or at least substantive, ones.
3. I tried to juxtapose the bad childhood of Michael Meyers with the (IMHO) bad childhood of these kids, not to imply they will become serial killers, but to suggest that maybe, oh, I don't know, once in a while, how we parent affects how the kids turn out.   Just saying.
4. The "obese white parents" comment. You know what? I have no idea why I wrote that. It's factual, but it was a completely prejudicial remark that I now regret writing-- it was nothing less than the promulgation of stereotypes. It highlighted things that have no relationship to the topic at hand.
4b. Except those attributes did have some relationship, otherwise it wouldn't have been on my mind. I wasn't born with the stereotype in my head.   I'm going to tread carefully, and I hope you'll appreciate what I'm going to say: I recognize that my thoughts were wrong-- i.e. a prejudice, but they came from somewhere-- even if that somewhere is an attribution or information bias. This speaks to the whole problem of prejudices in general, where they come from and how we combat them.

Here's an example: when I wrote that comment, my thoughts were exactly this: "I better let everyone know they were white, or else they're going to assume they were black." Think about that.

Strangely, it never occurred to me not to write they were obese-- another prejudice on my part. It surprises and frightens me that I could have and execute thoughts so automatically, without any consideration. It never even occurred to me that writing "obese"was in any way wrong.
5. "Torture porn." People took issue with it because they think porn gets defined as "what other people think is bad." As a working definition, porn can be anything that causes sexual excitement in the absence of the fetishized object. Think of it like this: porn's natural outlet is masturbation. There's no actual naked coed with you. The masturbation is the end in itself.
What about when porn leads to actual sex, with, say, your wife of 15 years? It's still masturbatory, in that your sexual energy is directed at the porn (e.g., how her hip looks like that pic, or how she moans the same way, etc.) Your mind fantasizes around the reality of your wife, so that the wife becomes a prop for masturbation. (This is an example, don't yell at me.) All of this is narcissistic, introverted. It's power over your own identity. Torture porn is the same: it's about you, and making the other simply an extension of your own affective needs. The point isn't to kill the person; the point is the killing. That's why torture porn is never about revenge, or crime, or any obvious purpose. The purpose is the exertion of your power. If there was a purpose to it, it wouldn't be masturbation.

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===== ====== ===== The Last Psychiatrist: This Onion Clip Is Hilarious; Now Let Me Tell You Why It's Scary

"This is our future," wrote the linking email. McLuhan wrote The Medium Is The Message but due to a printing error, it came out Massage. Proving his point.

Police Still Searching For Missing Productive, Obedient Woman

I got this Onion video as a link in my email, and the subject heading was "this is our future."

Which makes it funny. But the more insightful, and scary, way of looking at the clip is to assume the clip is occurring not in the future, but in the present, now. Then the video isn't a description of the future, but a study on how to manufacture reality.

I.

Imagine that American life is exactly as it looks right this second, but the Chinese bought one or two or nineteen news programs. (NB: this is not a post about how the Chinese are taking over the world, I have a different point. Follow with me.)

Say they wanted to influence American culture to become more Chinese, and also convey an impression about the Chinese as hard working, etc. So, they create a news program like this one. Initially, you'd laugh, just as you have already laughed. But over time the program would appear ordinary-- especially if all of the news programs were the same. You would watch this in your non-Chinese house, and slowly, over time, the media images would chip away at your conception of reality until it seemed completely normal that two white people are talking in Chinese-isms, judging a person by their industriousness, etc.

You probably remember the name of the program, but not the name of the missing woman. See? A story about Chinese culture makes you consider the merits of Chinese culture. But a show like this, that is about something else, makes you assume that this is already known to be the way Chinese culture is.

At some point the news version of China would contrast with your own life experience of China, and one would begin to dominate. Oh, you don't have any actual life experience with China except from TV. Hmmm.

How long before you start to accept the value system promoted on the news? In this case it's industriousness, but I hardly need to tell you it could be anything at all.

II.

Look at the husband in the clip. He is confused by how the anchors are acting. His world is the real world, where very little Is Chinese. Now he's crossed into this other world where everyone is acting like it's perfectly ordinary to be Chinese.

That's what it would look like for the first year or so-- confusion, dissonance. After that, we'd just accept it.

Note well that the two anchors themselves also live in the real world. They are perfectly aware that what they are doing is fake, invented, or even exaggerated. But they don't think they're lying, they just think they're doing their job. They don't appreciate that what they are doing is literally altering reality, permanently, for 300M people.

"How is the world ruled, and how do wars start?" wrote the journalist Karl Kraus. "Diplomats tell lies to journalists, and then believe what they read."

And onwards down the chain.

III.

Let's pretend the news clip and station were real. I'm sure China itself isn't like this news portrayal of China-- they are creating an impression, a product, and packaging it for American consumption, which, because there are no serious alternatives, would become the default worldview of Americans. The Chinese could make us think whatever they wanted. They could actually not even exist-- but we'd nevertheless believe that these newscasts are representative of typical Chinese life. Even if we went to China and found it completely empty, when we'd returned we'd still doubt ourselves: maybe we saw only a little part of China, surely those reporters have much more experience and information, it's not possible that they could be wrong and no one has noticed...

The image of this China is a product to be consumed. A product doesn't find a market, a product creates a market. Or did I do some market research and learn we needed a critical psychiatry/movie review blog written by a pirate?

In my description of this video, I'm pretending this is an organized effort by "the Chinese" to influence our culture; in other words they have a set plan. Our current media doesn't have such an organized plan. Individuals might use the media to push their own agenda, but the heads of the news programs don't meet in Switzerland to map out a plan of cultural propaganda.

Which makes it worse. Lacking a direction, a goal, means that reality is subject to whim. We used to care about Renee Zellweger and Islamic terrorism. Now we don't. Did they both disappear? Never exist? What?

IV.

There's a correlate to this, I'll explain by example: most people don't know anything about China. So this video clip, while funny, also seems kinda accurate-- based on what you've seen from other completely unreliable descriptions of China/Japan (e.g. The Simpsons, youtube clips, etc.) Or it might be dead on accurate, how would would you know?

Your objective baseline would come from... that same media. Ok, not the same program, but the same station, the same biases.

So the odd correlate is this: the media doesn't just tell us information, it educates us. It does what one might have ordinarily assumed a school would do.

Question: in what grade would a student nowadays learn about, say, the Carter Administration? Asked another way: if an 11th grader today knows anything about the Carter Administration, where would he have learned it?

You're all being home schooled, by the parents of someone else.

V.

First the sign describes reality. Then the sign replaces reality.

The media creates a shadow reality that regular reality must adapt to. When a politician cheats on his wife, then gets on TV and apologizes, no one in their right mind believes that the apology is sincere-- "it's all for TV."

The news media make it sound like the "public demands an apology." But the public doesn't, the news media does-- they need it to fill the time. The apology becomes TV segment; whether the apology was only for the benefit of TV becomes another TV segment; etc. No one believes it, yet there it is, filling up hours of TV news.

But despite the public not wanting this apology, and despite the news media needing it to kill time, this bit of fluff changes reality, it changes the way you think. Consider what would happen if the politician did not apologize on TV. The media would flip out-- "this guy doesn't even apologize!" and you, the ordinary guy, would feel some level of anger, or at least incredulity, at the lack of a fake apology you'd never believe anyway. You've come to expect a fake apology-- not even a real one-- as necessary to the way politics is conducted. So on the one hand cheating signifies we can't trust the guy, but on the other hand a fake apology means... we can?

"But the fake apology is part of the image..." My point exactly. We agree the image is neither real, accurate, nor important; but we've also agreed to limit all of our dialogue and thinking to the image and nothing else.

"But the image can stand in for the substance, it's a proxy." No, this is first grade semiotics. It doesn't represent reality, it becomes reality. If it's a proxy for substance, when do we actually talk about the substance?

The news doesn't just influence our values. It changes the way we think so that certain values become inevitable.

VI.

But what about issues that are too complicated for journacation? Then you create a proxy who says, "don't worry, I'll do the thinking for you."

Hence journalists and anchor people who break the fourth wall, become personalities and thus stand-ins for the complex analysis.

(if you don't see a video in this space, download Adobe Flash 10 or click the link below.)

I Am CNBC: Maria Bartiromo from Broadcasting & Cable on Vimeo.

I have seen these promos hundreds of times, each CNBC reporter has one. I found them eerie, haunting, uncanny and unreal, and I didn't know why I felt this. Now I know.

1.

The first question that any good post-postmodernist (e.g. mercantilist) might want to ask is, why, if they're sitting right there for the filming, do they use a voice over? Why not simply speak the words into the camera? After all, that's what they do all day anyway, right?

The answer is that at that moment, in that promo, that isn't their voice talking to you; it is your mind's voice running through what you "know" about them. It's the kung fu program in the Matrix. They've placed info into my head to use: "She's a smart/trustworthy person..."

So she's a substitute for my own analysis-- I can just adopt hers, because she's like me, trustworthy, etc. Hence the use of TV news lingo ("socialized medicine", "both sides of the abortion debate" etc) by regular people in ordinary conversations. Ok, nothing new there.

But the switch is that she is extending her "legitimacy" to CNBC, not the other way around. CNBC has managed to con you into thinking that they aren't the ones creating and analyzing the news, but that she is-- and you can sure trust her, she worked in a restaurant! If there was truth in advertising, the producers of CNBC-- not to mention the GE execs who own the station-- should be doing "I Am CNBC" promos. But that would be contrary to the purpose of the videos.    They make her more real so that their existence becomes less real.

2.

The second reason these promos were so eerie to me I only discovered months later:

CJR:

Gasparino taped the ("I am CNBC") spot, and submitted to another hour or so of extended self-revelation for the CNBC.com Web site, on September 15, the day Lehman Brothers filed for Chapter 11 bankruptcy protection... Erin Burnett, the luminous mid-morning anchor... taped her spot that day too. All thirty spots were taped between the fifteenth and the eighteenth of September, arguably the most turbulent four days in the history of finance, and thus one of the stranger allocations of newsroom resources in recent media history.

Of course.   But the CJR writer is wrong on one point-- this is exactly the kind of allocation of newsroom resources you'd expect when reality is about to be manufactured.

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===== ====== ===== The Last Psychiatrist: This Shall Pass

If you do not need to sell, don't.

The markets are tanking more than is necessary for even the most severe recession. What makes it scary is that it is happening in days, not months, relentless-- it's happening in internet time.

The S&P500 goes to 800 and Dow to 7500, these are inevitabilities. But you can't trade it because the volatility is too high-- so don't.

Some people need to sell-- especially hedge funds caught the wrong way; or people selling the good stocks to raise money to cover debts, taxes, redemptions, whatever.

If you have cash and can wait for 800 and 7500, then feel free to buy then. Stocks aren't falling, they are being stomped on, compressed. When the real companies rebound, their stocks will likely explode higher, like.. a coiled spring.

Let me quote the late, great, Mitch Hedberg: "I'm tired of following my dreams. I'm just going to figure out where they're going, and hook up with them later."

Don't follow the market. Just meet it at 800.

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===== ====== ===== The Last Psychiatrist: This Time It's ESP

I knew this was going to happen

Let me clarify one point about the MMR/Wakefield controversy. The fact that Wakefield faked his data does not prove there's no link. Right? I don't think there's a link, of course, but what do I know? I'm a pirate.

There's a controversy about a paper published in the Journal of Personality and Social Psychology, a highly reputable academic journal. The paper is about ESP, which is the controversy.

Either (NYT):

Journal's Paper On ESP Expected to Prompt Outrage

One of psychology's most respected journals has agreed to publish a paper presenting what its author describes as strong evidence for extrasensory perception... The decision may delight believers in so-called paranormal events, but it is already mortifying scientists.

Or (NPR):

Could It Be? Spooky Experiments That See The Future

One of the most respected, senior and widely published professors of psychology, Daryl Bem of Cornell, has just published an article that suggests that people -- ordinary people -- can be altered by experiences they haven't had yet. Time, he suggests, is leaking. The Future has slipped, unannounced, into the Present. And he thinks he can prove it.

All depends on whether you think "scientists don't know everything, man!" or "scientists are fraudsters, man!"

II.

The experiments are of the type: two groups take a test; one group is then shown the answers, the other group isn't. The ones who see the answers after the test did better on the test. Weird, right?

The paper describes nine unusual lab experiments... testing the ability of college students to accurately sense random events, like whether a computer program will flash a photograph on the left or right side of its screen. The studies include more than 1,000 subjects. Some scientists say the report deserves to be published, in the name of open inquiry; others insist that its acceptance only accentuates fundamental flaws in the evaluation and peer review of research in the social sciences.

"It's craziness, pure craziness. I can't believe a major journal is allowing this work in," Ray Hyman, an emeritus professor of psychology at the University Oregon and longtime critic of ESP research, said. "I think it's just an embarrassment for the entire field."
Hyman is right but for the wrong reasons, for self-serving reasons, which makes him wrong.   And the NYT assertion that this "accentuates fundamental flaws in the peer review of research in the social sciences" is also wrong, wrong, wrong, wrong.

There's a subtlety to the experiments that is indeed explicit in the articles but is easily overlooked, so I'll quote from the study:

From the participants' point of view, this procedure appears to test for clairvoyance. That is, they were told that a picture was hidden behind one of the curtains and their challenge was to guess correctly which curtain concealed the picture. In fact, however, neither the picture itself nor its left/right position was determined until after the participant recorded his or her guess, making the procedure a test of detecting a future event, that is, a test of precognition.
This is the part that's important. If it was a study of clairvoyance, well, could there be a possible physical explanation? Perhaps. But time travel?

Which is why anyone who says this study "doesn't belong in a scientific journal" is wrong. It doesn't belong in a psychology journal: this is an experiment about the laws of physics, not the laws of psychology.

And so to say that it is a failure of peer review-- like they did with Wakefield-- also misses the point. Bem's peers are in absolutely no position to review this. This study is better reviewed by physicists. Bem himself makes an explicit case for quantum entanglement! So notwithstanding my own rants about peer review,

"Four reviewers made comments on the manuscript," [said the journal's editor] "and these are very trusted people."

Trusted though they may be, they are not experts in the field being studied.

All four decided that the paper met the journal's editorial standards, [the editor] added, even though "there was no mechanism by which we could understand the results."

Exactly. So you should have sent it to the physicists. You know, the ones who work a building over in the same university that you do. That was the whole reason for universities, right?

No, I'm a dummy. The purpose of universities is to suck up Stafford loan money. And the purpose of journals is to mark territory, more money in that, like a corporation that spins off a subsidiary. NO CROSS SCIENTIFIC DISCUSSION ALLOWED IN SCIENCE, EVER, EXCEPT IN SCIENCE, NATURE, AND THE POPULAR PRESS.

II.

So I'll be explicit: peer review may have problems, but the entire way we evaluate science is territorial and stuck in the 19th century, which, ironically, was a time when scientists were much less territorial and practiced multiple disciplines.

With a data feed to select articles on "psychiatry," what do I need a psychiatry journal for? If you wanted to be brain scientists, why do you have separate journals form other brain scientists?

How awesome would it be to have an astrophysics grad student or a PhD economist or a dancer or anyone of the mofos from metafilter to come look at a psychiatric clinical trial and discuss it? You wouldn't have to pay them, they would think it was fun-- what, you think I'm blogging because of the millions of dollars in donations I get from Denmark and now the pacific northwest (6x in a month-- did you guys find a work around for Cybernanny?)

And no, not just the paper data; why not video the whole process and upload it? I have a phone that shoots HD 720p; good enough for the optical demands of amateur porn, why not good enough for science?

If researchers published their paper along with all of the primary source data on a web page, and let the public wikipedia it up, we might discover that a study was crap but we might also learn something about how studies become crap, the biases or hidden pitfalls, etc. (No, "available upon request" does not cut it.)

Instead, we have a near idiotic controversy occurring in self-imposed darkness.   "It's a big butt!"   "No, it's a big leg!" "No, it's a weird snaky-thing!"   "Well whatever it is, don't turn on the light, let's just keep guessing-- this way we can all get publications out of it."

===== ====== ===== The Last Psychiatrist: This Will Either Mean Something To You, Or It Won't

It's a heavy moment, the first time you realize you are older than Han Solo.

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===== ====== ===== The Last Psychiatrist: Those Five Days Matter More Than Anything, Except The Other Days
Guys, remember that time when you were 24 and you were on the subway, and you saw that girl with the glasses reading a book wearing a black leather coat, and you were obsessing over whether to go up to her or not but then your stop came, and you were like, screw it, she'll probably mace me, so you got off and went to the library to study for your chem exam?

You chose wrong.

In the Atlantic appears First Person Plural, an article about the growing evidence that identity is more complex than a simple collection of traits and beliefs.

The view I'm interested in... accepts that brains give rise to selves that last over time, plan for the future, and so on. But it is radical in that it gives up the idea that there is just one self per head. The idea is that instead, within each brain, different selves are continually popping in and out of existence. They have different desires, and they fight for control--bargaining with, deceiving, and plotting against one another.
Examples from the article include the hidden zero effect, in which choices are made differently depending on how far in the future are the payoffs. We can't imagine well who we will be in that future, so we choose what is better for the person in the now.

Personality also changes according to situation; even the most thuggish teenager is not the same around his buddies as he is when having tea with Grandma.... In the 1920s, Yale psychologists tested more than 10,000 children, giving them a battery of aptitude tests and putting them in morally dicey situations, such as having an opportunity to cheat on a test. They found a striking lack of consistency. A child's propensity to cheat at sports, for instance, had little to do with whether he or she would lie to a teacher.

With rare exception (of personality structure), who we are has a lot to do with what's going on at that moment. Hence the Nausea-- the feeling when you understand that there is no "you"-- at any moment you can decide to do or be anything. You didn't murder that guy because you're not a murderer. You didn't murder him because, well, it didn't come up.

II.

Yet there are an abundance of studies showing character traits are inherited; that behaviors are often predictable; and our own daily experience that there is at least a common thread to our identity. What of that?

Bad faith. It appears there's a commonality because, simply, we are not tested. But, more accurately, one is never tested; only parts of his identity are tested at a time. That's why the loving family man who then becomes a Nazi is still a loving family man-- that part was never strained. He is a good person and a bad person. Multiple selves.

The question is not whether traits are heritable-- they are-- the question is what self you are going to let dominate.

III.

Here's an example, from Barron's:

But such gloomy sentiments aren't a reason to get out of the stock market... Consider that $1 invested in stocks from February 1966 through May 2007 would have grown to $16.58 in that period. That's a 7% annual return.
Awesome, and by awesome I mean what a complete waste of one's life.

Somehow people demote investment income over any other kind of income. It's important to go to work every day, or clip a coupon, but it is nigh impossible to people to open a Roth. The money, I guess, doesn't seem real.

That's money; but if I grabbed the average teenager and told him his life and happiness would grow at 7% a year, he'd probably kill himself. 7% to the young is basically telling them not to even bother. To be young means you still have hope, that your energy and talents will eventually payoff, in a big way. The difference between a mature adolescent and an immature adolescent is not their expectation of massive success-- they both think they're going to rule the world-- but how they see it happening. Mature kids see a steady climb to awesomeness; immature kids see it happening one day, all at once, at some arbitrary point in the future. I know this because I see them in Starbucks, laptops open, staring out the window. I was one of those kids, too.

7% a year financial growth isn't good, it's a pacifier, a hoax (it serves, therefore, the same social function as psychiatry.) Furthermore, it can be wiped out in one week. If you bought and held over the past ten years, you made nothing. It was all a waste. Don't believe me? Go ask a retiree.

And you shouldn't accept 7% growth in your life, either. Every day must be a struggle for self-improvement in the service of improvement of the world.

IV.

Well, it turns out it is much worse than all that. Barron's again:

By contrast, investors who were out of the market in the five best days each year during that span were left with only 11 cents.
The implications for money management are obvious, but for life they're nauseating: if you take out the five most significant days of each year, then you are basically a completely different person. By money analogy, taking out those five best days made you massively worse off. You would have been better off not even going through the year. Studying for the chem exam always seems like a good idea, but there's an opportunity cost. And you have to measure that opportunity in real time, because in retrospect it will be too late.

The old generally think themselves exempt from this, but they are not; a day can alter their entire existence and legacy. November 4 will change how we remember John McCain forever. Nothing beside remains.

Who you are is a product of your experience, and also a product of the experiences you did not have. You didn't talk to that girl, now that's part of you-- you are the guy who was too scared/angry/self-absorbed/whatever to talk to her, and that is an entirely different guy then the guy who does talk to her and it works; and an entirely different guy from the one who gets maced. That was one of the most important days of your life, and you didn't even know it. Which brings me to the real point: every day is the most important day of your life, and you don't even know it.

there are worse things than
being Alone
but it often takes decades
to realize this
and most often
when you do
it's too late
and there's nothing worse
than
too late.

-- Charles Bukowski

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===== ====== ===== The Last Psychiatrist: Three Vignettes You Won't Understand Until I Explain Them, And Then It Will Be Too Late
Hint: what do the doctors not do?

1.

I say, "Hi, Dr. X? My name is Dr. T, from University Hospital, we have one of your patients here, Joe Blow, and he says he is on a very large dose of phenobarbital, so I'm trying to verify his doses and his seizure history."

"I know Joe, and his phenobarb does is 500mg per day with Dilantin 500 per day. He has intractable seizures from several head traumas about ten years ago. Other than that, he has no other medical issues."

"Wow. Well, thanks for your help."

"No problem. Bye."

-----

2.

beep

"Hello, Dr. Alone, this is Dr. Ted, calling you back about John Smith. According to the chart, I last gave him a prescription on 11/17, and at that time I gave him HCTZ 25mg #30, Percocet #60, and Prevacid 20mg. If you need any more information, you can call me back at the same number. Thanks."

end of new messages

-------------

3.

The medical student hangs up the phone. "That was fast," I say.

She nods. "I told him I was a medical student at University Hospital, and that we were trying to verify his medical history, but Dr. Block said he didn't remember Mr. Robinson so he said he'd have to have the nurse call me back to read the chart."

"Oh," I say.

----

What these stories have in common is this: the outpatient doctor did not bother to ask why his patient was in the hospital.

That's universal healthcare; or at least Medicaid and Medicare. Some doctors know everything about their patient, others know almost nothing, there's a variance but what's becoming more common is an apathy and disinterest in the maintenance care, the "across the life cycle" total patient care.

They figure: he's in the hospital, so presumably he'll be managed. I don't have time for this, I'm busy, I have-- well, patients to see.

The outpatient doctor isn't a "gatekeeper," he is simply a member of a large, disconnected team of clinicians who each care for a different medical and temporal aspect of his life. We are all consultants now. Contact between clinicians is usually about the past-- what did you have him on?--- or the short term future-- when can he see you next? It is almost never about the "total patient," integrating neuro with surgery, derm with endocrine...

The odd exception to this is psychiatry, but only private practice psychiatry. Community mental health is still a type of temporal consultant: if he shows up, you treat him.

When was the last time you talked to the internist of a patient about why/how you're putting him on Zyprexa?

I'm not any better, I'm afraid. The system isn't set up to care, it's set up so you care less-- because the less investment you have in being the gatekeeper, the more freedom everyone-- other clinicians who may bump into him down the line-- has in doing what they think is best. I hardly need to point out that not only are we not paid for consulting with other docs, but we lose billable hours and introduce each other to higher liability because they're now on record as being privy to my crazy Depakote + Cytomel+ testosterone plan. And no doc dares d/c the meds of another without good resaons-- good reasons that unfortunately no longer include "holy crap, that doctor is an idiot!"

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===== ====== ===== The Last Psychiatrist: Tiger Woods, Part 2

I had hot sex with Tiger in 2002

(part 1 here)

VII.

"I hate your cryptic, self-indulgent wanderings."

No one can be told what the Matrix is.

VIII.

A woman asks why a man risks his marriage because she's seeing it from the other side: what else could this nut want?

They think what he wants is something. What he wants is to be seen as something.

This is what every man and a certain kind of woman asked in 1998: "Bill Clinton was President, he could have had any woman he wanted, he chose Monica Lewinsky?" No, he had to become President to be able to get Monica. That's the size of the power differential that was necessary for him to feel relaxed and confident that a woman liked him. If he had tried to get someone like, say, Cameron Diaz (who was also famous at that time for doing nearly nothing) he would be thinking, "oh my God, this woman can totally see I'm a dweeb."

At some point in the relationship of TigerWoods and ElinNordegren he felt himself become Tiger Woods to her. It is irrelevant whether or not this was true for her; in his eyes, she was seeing Tiger Woods. Why would a swimsuit model with a likely prior history of adequate penises get horny over a guy with a flabby belly?

"Doesn't he love her anymore?" Of course he does. She doesn't love him, not like she used to.   She doesn't lust for him.

"How do you know that?" I don't need to know it, Tiger thinks it. If it took one billion dollars to get her interested in him, how much is it going to take to keep her interested in him, at the same intensity? It's impossible.

"That's crazy. Who thinks like that?"

Tiger Woods. Et al.

That's the problem with living in an era of narcissism. Even if you aren't one, you're not sure about anyone else.

IX.

"The best thing he can do is go on Oprah, admit his mistakes, maybe go into therapy to try to figure out what makes him cheat..."

He was with several women multiple times over many years. He didn't make a mistake, he didn't stray, that's who he is. You don't get to say who you are, your behavior speaks for you.

Trying to understand why he "cheated" or "strayed" or "made mistakes" is bad faith. Those behaviors aren't deviations from his normal, those are his normal. You can't isolate a behavior and unhook it from the overall self. "I'm not a bad person, but I do cheat sometimes." No, you are a bad person. The behavior is your business, but you don't get to commandeer the language.

X.

"So how can he stop doing it?" Are you talking about him, or you?

You can't try to understand why you cheat in order to stop, you have to stop first. And you can't permanently alter a behavior without changing who you are.

After much soul searching, I have decided to take an indefinite break from professional golf. I need to focus my attention on being a better husband, father and person.

I know it's a press release, but the words are technically accurate. Nowhere does it say "I have to stop cheating," because if he simply stops cheating then he will forever be fighting against himself. He has to also change into the kind of person who does not cheat.

There's no turning back, there's no half way. Once you stop you will be a different person. Many of your other interests will change, some of your friends will change, you will think differently.

If this proves too difficult, try a different approach. Instead of being the kind of person who doesn't do something, become the kind of person who does do something else that interferes with it. Become the kind of man who is proud of his fidelity. Or, at the very least, the kind of man who understands that he doesn't have to be TigerWoods to get a girl, and if he does, he doesn't want her. And she doesn't want him, either.

---

See also:

How To Lose Weight

Action Movie Fairy Tale

----

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Time Magazine Asks Cleveland Clinic What To Do About The Healthcare Crisis

This would be like Jimmy Carter asking Leonid Brezhnev what to do about Soviet military power, which, like this issue, actually happened.

They had a slideshow, but I was pretty sure they weren't labeled correctly. So I fixed them.

phew

"Not too much, now" (this suite will get paid for by your heart disease)

the new business of healthcare is business

===== ====== ===== The Last Psychiatrist: Time Magazine Stays Out Of the Election

Look at the page for three seconds only. Guess which party Time favors?

Some things to observe:

The "Yes" vs. "No" impact visual impact. Questions could easily have been phrased another way to generate "No" Democrat responses and "Yes" Republican (e.g. "Should the Bush tax cuts be maintained?")

The quotes underneath the candidates photos seem to starkly contrast the candidate's different philosophies. See how McCain's answer seems out of touch?   Notice the questions aren't published, only the quotes. Do you know why? Because they're not asked the same question. The Democrats are answering questions about the housing crisis, while McCain's quote actually comes from a speech to the Orange County Hispanic Small Business Association. You can see that in that speech, there are a number of quotes that could have been used that specifically relate to the housing crisis; instead, they picked one that has nothing to do with housing. So it appears he thinks abandoning the AMT is his solution to the housing crisis. "Stupid Republicans all think cutting taxes is the solution to everything."

Not fair, Time Magazine.

---

Addendum: I wrote to the editor about a week ago. No response.

===== ====== ===== The Last Psychiatrist: Time's Person of the Year Is Someone Who Doesn't Actually Matter

That would be you.

The short version of the Time article is that we as individuals have formed a community on the internet (YouTube, MySpace, Wikipedia, etc), and this community is starting to "build a new kind of international understanding, not politician to politician... but person to person."
Ok, no. Wrong, wrong, wrong all over the place.
The author of this piece is Lev Grossman. Grossman is fairly famous book critic, one of the better ones.   He also wrote a novel that's a nod to Borges. This isn't bad, it's just context.

The entire problem with Grossman's premise is exemplified by his first paragraph:
The "Great Man" theory of history is usually attributed to the Scottish philosopher Thomas Carlyle, who wrote that "the history of the world is but the biography of great men." He believed that it is the few, the powerful and the famous who shape our collective destiny as a species. That theory took a serious beating this year.
Well, not exactly. Grossman's thesis is that we matter, we can shape our destinies; he puts that in contrast to Carlyle's premise that great men help shape destiny. But that's not what Carlyle actually says. Here's the actual quote:

In all epochs of the world's history, we shall find the Great Man to have been the indispensable savior of his epoch;--the lightning, without which the fuel would never have burnt. The History of the world, I said already, was the biography of Great Men.
Carlyle doesn't say great men shape destiny; he says great men, and only great men, cause history. These great men should be given power to run society because only they can be trusted to do it. Great men actually drive history, not shape it.
Democracy can't be trusted. Paternalistic socialism, or at least a non-hereditary, anti-capitalist, aristocracy is all that can keep us from the dark of ochlocracy. Individuals trump ideology-- which sounds like a good motto, except when individuals means Stalin and ideology means liberalism. Oh, and the last book Hitler read was Carlyle's History of Friedrich of Prussia.
So Grossman is not really paraphrasing Carlyle correctly. This is important because Grossman is a book critic with a PhD from Harvard in comparative literature. Either he simply did not know this about Carlyle, which I have to assume is impossible, or it didn't matter: he commandeered the quote, stripped it of the meaning Carlyle intended and used it the way he needed to use it. And that exactly describes the problem: truth and reality aren't important, what's important is you.
Because "You" as Person of the Year is actually quite portentuous. It's is both representative and symptomatic of the problem of our times: narcissism. Nowadays we are so alienated and matter so very little to larger society that the only thing that inflames any passion is to be reminded of this. Consider Bush and Cheney. Put aside politics for a moment, it is clear that their single-mindedness of purpose ignores each of us as individuals. Give them the benefit of the doubt, that they are doing what they think is best. But it's best for society, for America: what we hate is that it isn't for us, for you, for me. That's what people hate about them, the seeming indifference to our individual worth, to our sense of importance. Our votes don't count; everything is about religion; "Global War On Terror." Where in all that is the individual? We are tools to their "higher cause." I know people say that they are angry at the cause; but I think it's really anger that we're being used for anything.
Being on YouTube, having a blog, having an iPod, being on MySpace-- all of these things are self-validating, they allow that illusion that is so important to narcissists: that we are the main characters in a movie. Not that we're the best, or the good guys, but the main characters. That everyone around us is supporting cast; the funny friend, the crazy ex, the neurotic mother, the egotistical date, etc. That makes reminders of our insignificance even more infuriating.
Take a look at the photos in the Time article: a DJ, a punk rocker, a guy in dredlocks, a kid dancing with headphones, a guy singing into a mic, a hot chick taking a photo of herself-- none of these people could ever be "Person of the Year." They barely have identities outside of their image. (And observe how so many are defined through music they listen to.) They must be defined by something from without, like a tattoo. But they deserve everything anyone else can have. It's their right.
I'm not saying each of us as individuals is insignificant. We should, could, matter. But to protect ourselves from an existential implosion, we decide to define ourselves through images and signs, rather than behaviors; lacking an identity founded in anything real makes us vulnerable to anger, resentment. But no guilt, ever. The narcissist never feels guilt. He feels shame.
It can't last. If society chooses to make narcissism the default, it's going to have to deal with society-wide narcissistic injuries-- when we suddenly realize that it isn't solely our movie and we're really not the main character. And no one wants to see this stupid movie anyway. This inevitably leads to violence: the school shooting, inexplicable knifing over Play Station 3, Andrea Yates, beating the wife because she wore the wrong shoes type of violence. Oh, they weren't white high heeled pumps? That bitch! She used to wear them for her old boyfriend.
I'm not sure anyone in psychiatry sees this-- they are too busy documenting Pharma excesses and Lamictal outcomes-- but it is the problem of our times. The only ones who seem to notice are advertisers, marketers-- they see it. They don't judge it, they simply profit from it.
Grossman could morph Carlyle into what he wanted because Carlyle doesn't matter, what matters is what Grossman wanted, what Grossman needed. Carlyle doesn't exist, or he only exists as we need to use him. He becomes a tool, another supporting character. Anyone actually read anything by Carlyle anymore? Why bother? We only need a few soundbites for our own use. Grossman is a clearly a good writer and hardly the problem here. But picking "You" as Person of the Year only reinforces the collective delusion that our individual selves matter more than other person, or a collective good, an ideology, truth, or right and wrong. It's relativism with a cherry twist.

It won't last. It absolutely can't.

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===== ====== ===== The Last Psychiatrist: To The Brain, God Is Just Another Guy

The most important question about any scientific study, that must be answered before any others are asked:

What do they want to be true?

Per NPR:

etc.

The study did make some interesting findings, but of course not the one heralded in the title or in the article.

The only true statement in the NPR article is this one:

A study of 40 people -- some religious, some nonreligious -- found that phrases such as "I believe God is with me throughout the day and watches over me" lit up the same areas of the brain we use to decipher the emotions and intentions of other people.

NPR, and the study's author, unfortunately concluded more than this:

Grafman says the finding, published in the Proceedings of the National Academy of Sciences, shows that there is no special circuitry in the brain that deals with religious belief. It also suggests that religion developed as the human brain evolved its capacity for complex social interactions.
Nope.

It's no stretch of the imagination to say that the majority of the NPR devotees-- and likely members of PNAS-- may not be outright atheists, but they're hardcore agnostics. They occupy that space preferred by the self-absorbed who aren't sure what they do believe, but fervently confident about what they don't believe: anything their parents were into. They're skeptical, but lazy; they "know" which things are not true, but can't be bothered to learn what is true, or at least make something up that is logically consistent. The exception to this is evolution: they are passionate about evolution, though woefully ignorant of any of its principles or mechanisms. Their zeal is partly in reaction to established religion, and evolution becomes a substitute for religion.

Articles like this one fortify them. They don't need the details; it's enough to know that science is discovering, bit by bit, that much of the intellectual or religious history of mankind over the past, say, 6000 years, is all crap.   It only took the sophisticated, post-Nixon mind to figure out what Kant couldn't. "Whatever, man-- evolution has a billion years on you." Indeed.

The study itself isn't too hard to explain. Subjects were asked to agree or disagree with certain god related statements ("People go to hell," "God protects all people") while their brain was scanned. The study found that the same regions were ones associated with understanding the intentions and emotions of human beings. Ergo: God is just another guy.

The obvious criticism is that this didn't study the religions experience at all; what it studied was what regions of the brain interpret statements that relate to intention. If they asked, "Jabba The Hutt thinks Leia is hot" it would have lit up the same regions, allowing the title of this article to be, "To The Brain, God Is Just Another Hutt."

Furthermore, it is very likely that many of these regions are only involved in linguisitic interpretations; if they had shown videos of people intending to do something, different regions of the brain would have been used.

But a more subtle criticism, and likely the most relevant one, is that this study was done on Americans born after 1970-- the Dumbest Generation of Narcissists In The History Of The World. Even if this was a valid test of how the brain deals with the religious experience, it's probably not applicable to how human beings in general, or over time, deal with the religious experience. If they tested, say, Carmelite nuns "thinking about God," you'd probably get different regions. (They did.)

In other words, the study emphatically does not show that "to the brain, God is just another guy." At best, it shows that American 30-somethings are not able to see God as anything other than just another guy; but who knows how 3rd century Romans saw God? Given that the study was done at NIH, by cognitive neuroscientists, published in PNAS and then reported on NPR, you would think that someone would have thought of this. Or perhaps they did, which is why they wrote it this way.

Of course not.

===== ====== ===== The Last Psychiatrist: Transgender Man Is On Women's Basketball Team, Sort Of

ceci n'est pas une personne transgenderee

From the NYT:

But Monday was anything but ordinary because it was the day the world would learn about the decision Allums had embarked on one year earlier: to come out as a transgender man playing on a women's basketball team.
Advocates for transgender athletes said they believed Allums was the first Division I college basketball player to compete publicly as a transgender person... a George Washington official said Allums would remain on the women's basketball team.
Got it? Transgender man on women's basketball team.

"I didn't choose to be born in this body and feel the way I do. I decided to transition ... I am trying to help myself and others to be who they are."

II.

In case you miss the nuance, here's the title: "Transgender Man Is on Women's Team." So in a progressive society, what are we to do with this? Should a transgender man be on a man's team, or a women's team?

But the more urgent question is, who decides what words mean?

III.

I defy you to read that article and figure out what the hell is going on. I know I'm not the only one confused, as evidenced by the comments on The Huffington Post, which I read when I have to go to the dentist.

And here is the first paragraph of Salon:

A transgender female-to-male basketball player at George Washington University is about to put the NCAA to the test. Kye Allums has been on the school's women's basketball team since 2008, but when the season starts later this month, the 20-year-old is premiering as a man. It will be the first time an openly transgender player has played Division 1 basketball
It is almost perfectly clear that what is happening is a woman who is now "premiering as a man" is on the women's basketball team. That this will still not generate any interest in women's basketball is besides the point.

The point is that what's actually happening is very different than the report. Let me summarize: nothing. A person born as a female is playing women's basketball. Also, she is still a female. She's never had surgery, never taken hormones, has no genetic ambiguity. At autopsy even the most radical activist is going to mark "F."

However, she prefers to identify herself as a he. That's it.

There is no controversy here, at all. It's just names. "From now on, I want you to refer to me as 'The Situation.'" Whatever.

This is a regular old female who is playing on the correct team (women's) and wants other people to call her what she thinks she is. But there are plenty of idiots who are applauding the college for... letting her play. As a woman. On the woman's basketball team.

IV.

Note that I have referred to her as "she," while she prefers to be called "he." The team has decided to call her "he" as well.

The real issue-- and why it's in the NYT and why you should care very much-- is who decides what words mean. I'll admit that how I define "he" is based on one set of principles, and how she defines it is based on another, and we differ on how those words should be used.

He is looking forward to Nov. 13, when Allums and the team will compete at the Best Buy Classic in Minneapolis. The game will be his public debut as a transgender man playing on a women's team

But the NYT is setting itself up as the arbiter, it is deciding for both of us what will be true. It's not taking up a scientific analysis of the question, it isn't even delving into the massive volume of mostly unreadable articles about gender issues. It is simply deciding.

It doesn't announce what it's done, it pretends it is already established to think like this. "We're writing it this way because of course everyone knows..."    Are you telling me that one of the most prestigious papers in the world did not know that the article it was writing was misleading? Confusing? It did it on purpose. And so did the AP. And every other media outlet that "reported" the "story." There's no story! Nothing happened!

But it has placed you-- the 100% of the world that thought they already knew what words meant-- on the defensive. "Oh, have I been doing this wrong all this time?"

They didn't do it because they care about the transgendered, they did it because they want to make it ordinary that the media decides what words mean.

That's the reason for the report, that's the reason the story is everywhere.

V.

Speaking of The Situation, you may have heard that on the show Jersey Shore, Mike "The Situation" may have made out with.... a "trannie."

The "cast" is repeatedly heard saying, "if you have to think about it... it's a trannie." Point is, The Situation wasn't sure it was a "trannie," but it was.

Or was it? GLAD got upset, and MTV apologized. I'm not sure what term they would have preferred, but I am sure of the purpose of the complaint-- and no, it had nothing to do with the "offensive nature" of the word "trannie."

What's obvious once I say it is that the "trannie" deliberately fooled Mike. He tricked him into thinking he was a woman. I'll state the obvious: if a man tricked a lesbian and blah blah blah.

There's no outrage at all that the "trannie" fooled Mike, and, according to GLAD, you're not even allowed to laugh about it. Partly its because the outrage has been usurped by GLAD, Cognitive Kill Switch style, and putting everyone on the defensive.

But that was the plan: obliterate a word ("trannie") that is derogatory but that has an actual definition. And that definition is: a man pretending to be a woman. Get rid of that word, and whatever word you use to replace it won't have that definition, it will be its own thing. So it couldn't have fooled Mike, it is what it is. It's the legitimization of a 3rd sex. Something that "is" what it says it is-- "a transgendered individual"-- can't ever be accused of pretending to be a woman.

And if that made no sense to you, thank God.

VI.

You can go back to the distraction of gender politics and semantics, go ahead and be hypnotized into thinking you must take a side, like the NCAA had to do ("planning a review of its policies.") Go ahead and believe your President is a socialist, or your former President s a racist, Kanye West has inside information. The game is over for me, I have enough rum to wait out the rest of my life. But the rest of you, especially the rest of you under 30, wake up. The day is approaching where the media will redefine what is right or meaningful, redefine you as meaningless.

And you'll believe it.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Treating Insomnia With Less
A grog of rum and an issue of The Economist should handle any sleep problems you may have. But, if you're one of those who think drinking alcohol is wrong but drinking psychiatric medications is right, then this is for you.

Most people think of sleep as the opposite of wakefulness, a line with two poles, you slide the switch back and forth.

In fact, there are two regions in the brain, working at the same time. A wakefulness promoting region, and a sleep promoting region, battling each other, and your mind, for supremacy.

Simply as a convenience to me for the purposes of writing this post, I'll call the "wakefulness promoting region" the tuberomammillary nucleus, and the "sleep promoting region" the ventrolateral preoptic area of the hypothalamus.

Explain yourself.

The TMN sends histamine projections all over the cortex. Histamine causes arousal, increased attention, perhaps increased learning and memory. All of these are good and holy things. Antihistamines are competitive blockers of H1 receptors; they block the histamine from binding and thus prevent arousal, etc. They are thus the work of Satan.

The VLPO sends inhibitory GABA projections everywhere to turn down/off places which are aroused by projections from the TMN. It also sends projections to the TMN itself, to turn it down/off, to Dark City you.

GABA agonists-- benzodiazepines like Xanax, Ativan, Restoril, and the "non-benzo" Ambien and Sonata type, and alcohol, delicious, delicious, alcohol, all work this way.

I like Xanax.

No doubt.

Is there a difference in the quality of sleep?

No, not really, individual results may vary but the main difference is how you feel when you wake up.

The problem with these GABA agents is that no matter how aroused you try to make yourself (through the TMN, coffee, or porn) you still have the effect of the drug lingering in your body. Hence, you can be an "awake drunk" or a "caffeinated masturbator." People may feel completely refreshed after 8 hours of sleep with Ambien yet still have decreased reaction times and impaired cognition as a result of the Ambien. It probably is mild enough not to be relevant unless you get up really early to perform surgery, but such people would never dream of getting drunk the night before or taking an Ambien. Right?

And the longer the half life of the drug, the longer it is in your body, the longer the effect is there (again, even if not obviously apparent.)

If, however, you are on a pure H1 blocker, then you could simply release more histamine (e.g. wake yourself up) to displace the drug from the receptor. An H1 blocker may be the way to go if you perhaps have to get up suddenly in the middle of the night.

I tried antihistamines like Benadryl, and they don't work. In fact, they make me feel wired.

Ah, many people have this reaction. You'd be surprised to learn that this is due to, and a screen for, very low levels of testosterone.

What?!

Psyche.

The real reason is that it isn't actually an antihistamine. That's misleading.

What do you mean, misleading?

You know how I hate the FDA, and most everyone else in the world, because they use words to distort the truth, and get girls to sleep with them that would never sleep with me?

What?!

Pay attention.

Here is the affinity chart for Benadryl:

(from CNS Spectrums)

The drug has the most affinity for H1 receptors, sure, but look what else it does. M1 blockade (dry mouth, constipation, confusion.) It also has significant NE and serotonin reuptake blockade. Basically, the FDA decided to pick only one of these four properties and slap it on the box, in the same way as labeling a TV dinner as "Rice."

You'll also observe that it looks like it works the same way as Effexor or a tricyclic. You'd be right. Think about that.

So every time I take Benadryl, it's an antidepressant?

Depends on the dose.

If you eat all of this TV DINNER, you'll be getting several foods. But if you only take one single fork of the rice, then the only thing you ate was rice, even though the box says, "TV DINNER."

If you only take a low dose of Benadryl, then you are only getting H1 blockade. If you take a medium dose, then you are eating only the rice (H1 blockade) and the cogentin (M1 blockade.) A high dose gets you all of the TV DINNER and receptors blocked (and also a heart attack-- hey, the analogy holds!)

If you imagine that the drug prefers H1>M1>NET>a1>5HTT, then you see that the mistake most people make with Benadryl is that they increase the dose when if doesn't work. What you really want to do is decrease the dose, to get away from all the other things that could be stimulating (serotonin, NE, anticholinergic.)

What about Trazodone? Elavil?

Highest bar=highest affinity= "happens at lower doses."

Trazodone works best around 50, not 25, because he first thing trazodone gets you (at the lower doses) is serotonin, not H1 blockade.

Elavil is not a good choice, because there's really no way to dose low enough that you'll avoid the other stuff (serotonin.)

So what's the best?

The best is tiny doses of Remeron (3.25-7.5mg) or doxepin (1-5mg).

I took Doxepin all the way up to 200mg, it did nothing except give me dry mouth.

Doubling the dose is not twice the sleep, it is the addition of entirely new drugs (receptor systems.) 3mg of Doxepin is 3mg pure H1 blockade. 100mg of Doxepin is 6mg H1 blockade, and some Cogentin (M1), Effexor (S/N) and Hytrin (a1).

You're saying less of these sleeping pills make you sleep better?

It's not just less. It is taking only a certain kind of receptor system, and avoiding others which wake you up.

What do you use to sleep?

I don't sleep anymore.

----

More on this concept.

===== ====== ===== The Last Psychiatrist: True Detective's Detective

taking part in a particular pleasure

[Pastabagel and I have emailed about the show. Some excerpts of his]:

In Episode 3, the preacher says to Cohle, "Compassion is ethics, detective" when he departs the trailer leaving the reformed pedophile Burt in distress. Cohle replies "Yes, it is."

But if Time was created so things could become, and if acting out of the interest of others is compassion, then we should assume that Cohle is "becoming", changing into something else. But what?

Cohle asks in Ep. 5 "Why should I live on in history?" It's an odd line, especially when in episode 1 he tells Marty that he "lacks the constitution for suicide." But he also meditates on the cross (as an atheist), "contemplates that moment in the garden, of allowing your own crucifixion." But by 2012, Cohle has changed. He's resigned himself to ending his own life, but only after settling this debt- doing what he owes. One last act of compassion before giving up the only thing he has. His life. And once he's willing to do that, then he can do all the things in his life that require selflessness, courage, etc (i.e. things that require faith). You have to accept the infinite so you can make the right moves in the finite.

And when he does this, when he resigns himself not to his fate but to his eternity of endlessly repeating, at that moment he will actually have faith, because that's when he proves he believes in the eternal. Only after doing this last good thing does he believe that he could stand the idea of an eternity of rerunning his life, because he knows at the end, he's fulfilled it. "Nothing is fulfilled--until the end."

According to Kierkegaard, this resignation to the eternal is crucial. Kierkegaard was not an atheist but a diehard Christian. He believed that when a man resigns himself to the eternal, to existing in eternity, and gives up everything that ties him to this world then he becomes a "knight of faith" capable of great Christian acts (like the self-sacrifice that is almost certainly coming in ep. 8). When Kierkegaard wrote about a Knight of Faith, he contrasted the Knight of Faith to the mere Knight of Infinite, the "God botherer"--a phrase used twice in the show. What did Kierkegaard say the Knight of Faith looked like? Like this:

Why, he looks like a tax-collector!" However, it is the man after all. I draw closer to him, watching his least movements to see whether there might not be visible a little heterogeneous fractional telegraphic message from the infinite, a glance, a look, a gesture, a note of sadness, a smile, which betrayed the infinite in its heterogeneity with the finite. No! I examine his figure from tip to toe to see if there might not be a cranny through which the infinite was peeping. No! He is solid through and through. His tread? It is vigorous, belonging entirely to finiteness; no smartly dressed townsman who walks out to Fresberg on a Sunday afternoon treads the ground more firmly, he belongs entirely to the world, no Philistine more so. One can discover nothing of that aloof and superior nature whereby one recognizes the knight of the infinite. He takes delight in everything, and whenever one sees him taking part in a particular pleasure, he does it with the persistence which is the mark of the earthly man whose soul is absorbed in such things. He tends to his work. So when one looks at him one might suppose that he was a clerk who had lost his soul in an intricate system of book-keeping, so precise is he.

[Here I said that the reference was clear, but that Cohle did not look like this at all, that he appeared much more like the knight of inifinite resignation, the "tragic hero."]

The point is that the writer is taking the concept and running with it. If we've already spotted Kierkegaard, Schopenhauer and Nietzsche, then we are firmly entrenched in the existential project, and we should expect to find references from other existentialists also. And we do. The preacher in 2002 tells us that God is dead ("only nearness is silence"). Ep 3 Marty asks Cohle the question from Dostoyevsky, "You know what people would do without God, it would be an orgy of murder and debauchery." Would it? Existentialists say no. Do we have Sartre? Why yes, we do. There's angst and despair all over the place. And the angst is brought on by the burden of freedom, not the absence of it.

Think how often Cohle ruminations on suicide echo Camus's formulation of suicide as the fundamental question of philosophy in the Myth of Sisyphus (a guy endlessly pushing a rock up a hill, over and over, repetition, cyclical.) But Camus answers it in the negative, faced with a meaningless world, you embrace the absurd and revolt, not commit suicide. And isn't what they are doing now a revolt? Kidnapping cops, burglarizing the houses of the most powerful figures in the state? If this group has been kidnapping kids, if they held power for generations in the state, if they are plugged in all all levels, then isn't acting against them so deliberately a revolt against power?

And if they are embracing revolt, if they are not embracing suicide (but are willing to make a sacrifice, is there a difference?) then they have embraced the absurd, and are on their way to the teleological moment ("Teleos de Lorca, Franciscan mystic"--a made-up guy that invokes Francis of Assisi a second time, reminds us of the teleological stakes, and re-invokes mysticism to bridge us from the ethical paradigm of the characters to the Continental philosophy started by Bataille (who was derogatorily called a mystic by Sartre, all in one shot, how is that for economy of storytelling, take that Cormac McCarthy)).

Revolt: "Fuck this world," Cohle says. Remember how he says it? Not in anger, almost off-handedly, like he's passing on the offer of a free lunch. No anger, no big explosion. Just...resignation. But he only gets around to trying to screw it 10 years after he says it. And in 2012, it's jumper cable time. No institutional rules. And no masked perversion of the established rules. (I'm a cop who's job is to uphold the law, and therefore I'm the one who can break it). Rather than commit literal suicide, they commit it metaphorically, by giving up and saying goodbye to everything to take on the very institution that defined their identity.

And if it is a revolt, then we invoke all the ideas of consistent with revolution? Do we push out of the existential angst of the 50's into the revolution of the 60's and beyond? The "present" in the show is 2012? Will we get a postmodern postmortem, an aftermath 2 years later set in 2014? And by then, how much more of the landscape will be swallowed by Carcosa, the corrupting refinery towers that loom in the back of every scene in the show?

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===== ====== ===== The Last Psychiatrist: TV Creates Its Own Enemies

the bomb came from A, the attack on America came from B

Contessa Brewer on MSNBC, about the Times Square Bomber:

"...there was part of me that was hoping this was not going to be anybody with ties to any kind of Islamic country because there are a lot of people who want to use this terrorist intent to justify writing off people who believe in a certain way or come from certain countries or whose skin color is a certain way. I mean they use it as justification for really outdated bigotry."

Contessa is an awesome name. Oh well.

It's safe to assume who she was hoping the bomber was going to be was a white guy from Nebraska. And the easy criticism here is that she is a leftist nut, so I'll leave it to others who make their living that way.

But the missed criticism is the second part of her quote. "...there are a lot of people who want to use this terrorist intent to justify writing off people who believe in a certain way..." That's all her. I understand she meant airplane pilots flying with only the right wing, but that's the whole point: she is not aware that form of her criticism applies equally to herself.

Which brings me to the second point: how many airplane pilots does she really think are going to use this incident as an excuse to hate Muslims? Those that hate Muslims don't need an excuse; those that don't hate Muslims are unlikely to be suddenly converted to Islamophobia.

"Those certain people" are other TV pundits. That's her whole world. That's why it seems to her like "a lot of people" will manipulate this story. The 30 or so pundits on either side that constitute her entire social and intellectual universe will most certainly use this incident to mouth off for the next trimester, but the average American barely cares at all. (Not a good thing either, and had it gone off a different story altogether. But.)

When you watch TV, especially the news, understand that they are merely arguing with themselves. This isn't "lose Cronkite, lose middle America." These people do not represent America, they are not in touch with America at all.

But, sadly, scarily, and certainly, they provide the language and framework that you will adopt wholesale. The intellectual problem isn't that some Pakistani nut tried to car bomb the Lion King, the problem is that our understanding of it will come from a gated community of idiots.

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===== ====== ===== The Last Psychiatrist: Two Causes Of Autism
Ah, finally, a post about science only, that doesn't offend anyone.

Whoops, sorry, that's my other blog. In this blog, I write about how the parents cause autism.

I.

First, let's get this out of the way: that was a joke, ok? I do not think autism is caused by the parents. Science has already disproven that link. Science shows it caused by rain.

Before any science is discussed here, take a minute and examine your prejudices, which run so deeply that I can't write a blog about narcissism without getting accused of writing too much about narcissism.

Why, when I wrote that autism was caused by the parents, did you think that was so offensively preposterous as to merit rebuttal in ALL CAPS? Yet when I said it is rain, you were... intrigued?

Not that you actually believed it was rain, of course, you figured that was a proxy for something else; but you did not allow that "parents" might be a proxy for something else. Linking parenting to, well, anything, is so loaded with connotation that it is safely beyond consideration; yet a moment's reflection reveals that of course that's the best proxy.

Science in psychiatry, or in any field that pretends to examine behavior, is a false god. It's not just the results that are biased; the way questions are asked, the questions that are asked, that can be asked-- and the ones that none dare ask-- safely protect even the sexy calf of the truth from ever being revealed.

Take a break, Diogenes, it's going to be a long wait.

II.

Well, what about all that rain nonsense?

In general, autism rates are higher in the norther U.S. than in the southern.

Looking at three states, Washington, California and Oregon, a study found the counties with the highest precipitation in the 1990s lead to the highest autism rates in 2005. Additionally, kids under three who experienced higher than normal rainfall relative to other years had higher rates of autism.

What's nearly incomprehensible about this article is the next sentence:

There are a number of possibilities concerning what such an environmental trigger might be.

It goes on to list their top four explanations, but in case you don't see it, I'll spell it out: this environmental trigger is one that occurs to the child after he is born, not before, or to the parents.

They cite: rain means more TV watching; Vitamin D deficiency; household cleaners or some other indoor toxin; or the rain brings an atmospheric or ground toxin into play.

The obvious problems with the study are myriad, but

Because we do not provide direct clinical evidence of an environmental trigger for autism among genetically vulnerable children that is positively associated with precipitation, our results are clearly not definitive evidence in favor of the hypothesis. But the results are consistent with the hypothesis, and, therefore, further research focused on establishing whether such a trigger exists and on identifying it is warranted.
No one on the planet is going to misinterpret this study as actually saying rain causes autism. What they will do, however, is hear your bias that it is something that happens to the child that leads to autism.

Which is exactly what you wanted, isn't it?

III.

Fortunately, there's an editorial, "Do These Results Warrant Publication?" in the same issue that critiques the study (e.g. reporting bias, etc) and then argues

that the authors' analysis and the editor's decision to publish it are to be lauded, despite the uncertain ultimate contribution of this work and the possibility (likelihood?) that nonprofessionals are going to misinterpret and misuse it.

You can say a study should be published despite misinterpretation, but why would you say it should be lauded if it is likely to be misinterpreted?

Not only was [cites numerous flaws in the study.] Nonetheless, I would argue, so what? The primary audience for the article of Waldman et al is not the practicing pediatrician, and certainly, it is not a member of the public at large. These individuals cannot take away any practical message from it.

Because people are idiots?

Of course, if a study's findings are no more than tentative ones... responsible authors will stress this, just in case members of the lay public are "eavesdropping" on the exchange of information between scientists.

He doesn't get it, at all. Or maybe he does? Repeatedly saying that the results are tentative, stressing the problems with the methodology, this masks and reinforces the ideological bias-- that autism is caused post-natally.

I believe that Waldman et al have indeed reported their results responsibly. They have made it clear that the message the public should take from their data regarding precipitation and autism is the same one suggested by an editorialist commenting on a recently observed modest association between prenatal exposure to cell phone use and behavior problems in childhood: "No call for alarm, stay tuned."

IV.

"Are you saying there can't be a component to autism that occurs after birth?"

How do I know? I have no idea. More importantly, they don't have any idea, either. I have the very same evidence available that they do; the question is simply impossible to answer so far.

I am aware, however, that there are plenty of possibilities, both post-natally and pre-natally. This study doesn't test the existence of "environmental triggers" because it could easily be explained by completely genetic factors: for example, that parents who are predisposed to having autistic kids choose to live in Oregon. (What, is that so insane?)

If his concern is misinterpretation and misapplication of a single study, then he should be aware enough to spot how it will be misinterpreted.

So it isn't misinterpretation that rain causes autism, but that this study has anything to tell us about environmental triggers at all.

The worry about the eavesdropping public isn't that they will read this study and hear, "rain might be involved somehow" but that they become convinced that there is an environmental trigger.

The study will adds to the study pool labeled "Evidence For Environmental Causes" and it simply isn't that. But when those studies are stacked up on top of each other, it looks like that.

V.

We can now reverse this discussion entirely.

There is considerable evidence that advanced paternal age, but not maternal age, increases the risk for certain psychiatric conditions but not others (e.g. schizophrenia yes, depression no) and increases massively the risk of autism.

I want you to take three seconds and come up with a plausible explanation for why that is.

You picked: defective sperm. Me, too.

However-- and this is the point-- you must recognize that there is nothing in the epidemiological evidence that allows you to jump to that conclusion. It is your bias that older father= defective sperm, i.e. that the older father is actually a proxy for a pre-conception risk factor, and NOT that he's too tired to play with the kid; or that any man who had to wait until later to have kids is semi-autistic himself, etc. All of those are prejudices, biases, unfounded in science, but they are exactly the same as believing it has to do with defective sperm.

There is circumstantial evidence, e.g. with mice, that older fathers produce progeny with various "problems": decreased exploratory activity, worse performance on avoidance tasks, etc, but nothing that would hold up in court.

Advanced paternal age could just as well be a post-natal risk factor as it could a pre-natal one; just as rain could just as well be a pre-natal risk factor as it could a post-natal one.

However, both camps have chosen a side and fail to consider the other side. They're already firm about when the problem started, or what kind of problem to look for. Dialogue is therefore impossible.

VI.

There is an additional twist to this story: the kind of autism (or schizophrenia) that is associated with advanced paternal age may be a different kind of autism or schizophrenia then the heritable kind.

To illustrate this, consider the happy discovery that in monozygotic twins (identical) have a 50% concordance for schizophrenia. Dizygotic twins (fraternal, non identical) have much less-- 10%-- the same as any other first degree relative. (For autism it's 60% MZ, 0% DZ.) This can easily be taken to mean, "it's genetic." End of debate.

Well, it really depends on what "genetic" means. You're going to want to sit down for this:

When MZ twins are divided between monochorionic (one placenta for both fetuses) vs. dichorionic (each MZ twin gets it's own placenta) you find slightly different concordances: 60% for the same placenta twins, and 10% for the separate placenta twins.

Remember, even though they have different placentas, their DNA is still completely identical. If schizophrenia was really mostly about DNA, then the placenta shouldn't matter. But it appears that placenta matters more than DNA.

The average reader will find this quite fascinating, but for me, the truly fascinating, jaw dropping part of it all is this: the article cited, above, was written in 1995. Since that time, no one has furthered this line of inquiry.

Not because the study was debunked-- no one tried to debunk it. It's simply too hard to study twins in this way, and since it is to hard, we pretend that it isn't important. The only analogy that comes to mind is a political one: it's way too hard to track down loose Russian nukes, so instead we'll continue to work on disarming ours.

Autism is a spectrum; schizophrenia is a spectrum, and not only are multiple factors involved, but likely specific factors are involved in specific subtypes only that we currently lump all together.

Add to that everyone's camping out in different corners of the nature/nurture octagon, and if you're wondering why over 40 years of research into the causes of both disorders we're still at the level of "rain," well, that's why.

VII.

It is my personal bias (emphasis mine and bold and underlined) that advanced paternal age is a proxy for both/either "defective sperm" or some diathesis of... developmental disorder... in the father. Either or both may be relevant for different cases. If someone wanted to do a second study, take the rain study and cross it against paternal age. Do older fathers live in Oregon?

So where is the real money in genetic research in autism and schizophrenia? More generally: where are we most likely to find "genetic" explanations for complex behavioral traits that defy simple "gene model" explanations?

Start by looking at the possible explanations for the genetic effects of advanced paternal age:

There are three main lines of thought.

1. Older sperm has longer time to suffer point mutations. Men's sperm is constantly (24 times a year) undergoing cell division, each time brings opportunity for mutation.

2. Expanding trinucleotide repeats.

3. Imprinting.

I believe with no hesitation that the money is in imprinting. Let me explain.

Part 3 In one week

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===== ====== ===== The Last Psychiatrist: Undue Influence On Psychiatrists, Or The Public?

This is an example of why the controversy over Pharma influence on doctors is, while accurate, likely irrelevant.

In Psychiatric Times, the Time Magazine of psychiatry, there appears a powerful juxtaposition of stories that was likely not appreciated by the editor.

The first story, "Vermont Psychiatrists Unduly Influenced" says what it looks like it would say. The attorney general finds that Pfizer, Lilly, etc spent $3M on marketing to doctors, a 33% increase over last year.

The second story is literally in the next column. "30% [of Americans] Have Received [Psychiatric] Treatment" especially people in their 20s-30s. Furthermore, the article notes there are still significant barriers to treatment-- so more people would have gone if they could.

Doctors are being paid to write these meds? Wait-- what, exactly, are they being paid to do? Write Zyprexa instead of Geodon, not with Geodon. And only to the people who show up in their offices. Right? These marketing efforts should result in skewed prescribing, but not more prescribing. In theory, the best Pharma can do is get everyone who shows up on meds.

The problem, bluntly, isn't that Pharma is getting docs to write prescriptions. The problem is that our beloved country is going completely insane. The supply of pills isn't the issue, the issue is the demand for them-- for anything, for relief.

At some point, someone needs to stop asking why docs are writing Zyprexa, and ask why people are rushing to psychiatrists. Did the gene for bipolar suddenly get activated by a viral pandemic? Or are there social reasons for this?

As if to further support my premise, the next article immediately below that one is "Drugs Easy To Get Online," saying that people are getting pills from online pharmacies without prescriptions. People want the meds, not even because they work, but simply because they are hope, they are a chance.

These meds are the wrong solution for what are largely social/economic/family problems. However, not only are there no other solutions; not only is no one even suggesting that these are social problems; current policy is to label these social ills as psychiatric.

I get it, it buys you about a generation. But not much more time than that.

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===== ====== ===== The Last Psychiatrist: University Shootings: I'm Sure It's All Just A Coincidence

While preparing the post on the unusual characteristics of the suicides at MIT, I looked up university shootings and found, well... draw your own conclusions:
Dec. 6, 1989: Gamil Gharbi, 25, engineering student at the University of Montreal, kills 13 women and wounds others (he released the men.)
Nov. 1, 1991: Gang Lu, 28, physics grad student at the University of Iowa, shoots his dissertation advisor and five people and himself.
Aug. 15, 1996: Frederick Davidson, 36, grad student in engineering at San Diego State, shoots three professors at his dissertation defense.
Aug. 28, 2000: James Easton Kelly, 36, a grad student at the University of Arkansas, dropped from the PhD program and shoots his dissertation advisor and himself.
Oct. 21, 2002: Huan Xiang, 38, senior at Monash University (Australia) uses five 9mms to kill two students and wound others before being subdued.
May 10, 2003: Biswanath Halder, 62, former student, returns to Case Western with two 9mm and opens fire, supposedly over a failed lawsuit against the school.
Oct. 28, 2002: Robert Flores, 40, Gulf War vet and failing out of University of Arizona Nursing College, comes in with 5 guns and shoots three teachers and himself.
Jan. 16, 2002: Peter Odighizuwa, 42, grad student recently dismissed from Virginia's Appalachian School of Law, shoots the Dean and a few others before getting subdued by students.
Sept. 13, 2006: Kimveer Gill (fun pics here), 25, opens fire with automatic weapons at Dawson College (Montreal), kills 20 and himself.
And, of course, April 16, 2007: , Cho Seung Hui, 23, the not mentally ill former stalker of two women who shot up Virginia Tech.
So graduate school is so stressful it makes people snap? Or is that just the Gulf of Tonkin?
Too old, too disconnected, too-- weird-- to be accepted or acceptable in a closed environment where social life is as important, if not more important, than academic performance; where individuality is really flavored homogeneity ("no, dude-- my iPod is white"); where "what frat?" says more than "what major?"; riding the internet while everyone gets a lot more sex, with a lot better looking people, than you; and, the last straw, your only claim to university related self-esteem gets forcibly "taken" from you.
And no, it's not the universities' fault, and it's not the media's fault, it's not mental illness, antidepressants, the "permissive society," porn, or lax gun laws. These are the convenient banalities politicians will use to appeal to a mindless base. No. This is what happens when you don't know who you are. And it is only going to get worse.

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===== ====== ===== The Last Psychiatrist: University Suicides On Schedule

I came across this in my regular survey of the internet: a student (?) listed all the suicides at MIT hung it up in a bus schedule frame.
The suicides' names, ages, method, etc, can be found here.
But there are a few notable findings:
First, you should know that MIT and Harvard have some of the highest suicide rates.
But, strangely, almost half of the suicides at MIT were grad students or former grads-- 13/30 since 1990. (Since 1980 , 16 grads at MIT vs. 8 at Harvard.)
Since 1990, there have been a lot of suicides by jump off a building-- 10/29. In the U.S., this is extremely rare, while in Hong Kong, 50% of suicides are jumps from buildings. (None of the jumpers here were even Asian.) (The only school that comes close is a rash of six jumpers in 2004 at NYU (no Asians.) The first three happened witin 30 days of each other, and the last two happened in the same week a year later. Only 1 was a grad student. As near as I can tell, NYU hasn't had any jumpers before or since-- in fact, they hadn't had any suicides since 1996.)
A lot were women: 7/29 (25%), 8/29 if you count the Wellesely student who was renting on campus. In the U.S., it's 15-20% females.
8/29 were non-white males; 4/29 were non-white females, so 12/29 were not white. In the U.S., non-whites represent about 10% of all suicides. And 2/3 of non-white suiciders in the U.S. are black.
February was the most popular month for suicides (6), January second place (4).
All three suicides that occurred in April (2000, 2001, 2003) were women. 2000 and 2001 were both sophomore women, who died on 4/10 (burning/OD) and 4/30 (cyanide poisoning.)
I don't have the demography of MIT, but it seems that grad students, Asians and women are at higher risk for suicide at MIT.
And if someone asks you how to get to the roof, lie.

(NB: MIT students, I know, small samples and statistical significance. I know.)
(Second NB: I looked into each suicide as best as I could, and I was able to supplement the spreadsheet linked above. For example, I found two additional jumps from buildings. But in this process it discovered that one "suicide" (KM) might not have been a suicide; and, even more interesting, he was linked to the suicide of another student at MIT (RG). I use the initials here, but their full names are clearly public, and already contained in the spreadsheet.)
(Third NB: to the guy who made the suicide schedule-- some of the dates and methods are wrong (for example, April.) Nothing major, but if you want my list let me know.)

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===== ====== ===== The Last Psychiatrist: Unpublished Lamictal Studies Left Us Thinking It Was An Antidepressant
If you cheat on your wife, and later learn she had cheated on you, can you say you cheated because she cheated on you?

An great paper by Nassir Ghaemi, saying-- and this is a quote:

Some things we know, and know that we know. Other things wedo not know, and know that we do not know. But perhaps the largestclass involves those things we do not know, and do not realizethat we do not know.

That kind of thinking exhausts me.

II.

Thus I was surprised to discoverthe existence of several negative lamotrigine studies... Of the nine lamotrigine related bipolar disorder studies postedon the website, two were positive and published... Five other negative studies involving rapid cyclingbipolar disorder, acute bipolar depression and acute mania havenot been published and are only available on the GSK website. Failure to adequately publish these negative studies led tothe creation of a clinical impression that lamotrigine is an"antidepressant," a view innocently expressed to me as recentlyas last week by an academic colleague.

At this point I need to take a nap. Ghaemi wrote one of the best books on statistics for psychiatrists; so I'm not defending the hiding of negative studies, but is this man seriously saying that the "hiding" of 2 negative bipolar depression studies is the reason an entire planet of psychiatrists thought Lamictal was an antidepressant when there never were any positive studies saying it was?

This is like Pfizer coming out and saying, "sorry we hid the negative data on Viagra and telepathy." Ok, what?

In fact, there were already three negative studies about Lamictal as an antidepressant published: the same three that said it wasn't an antimanic either, but only good for the "prophylaxis of mood states," which is like the rock that keeps tigers away.

The fact that his academic colleague called it an antidepressant means, simply, that he's an idiot. No, no, no, I'm not being disrespectful, I mean it completely seriously. He's an academic. He's supposed to know what the (only) three studies say, especially since he's teaching it to other people; and he's apparently prescribing this thing thinking that it is an antidepressant based on nothing at all. Ok, maybe not nothing: based on the word of mouth from other people who didn't read the same three articles.

Does Ghaemi think that the unveiling of negative studies is going to change the behavior of a person who is making it up as he goes along anyway? It doesn't stop astrologers, does it?

III.

Don't look at me like that. Five years ago if I stood in front of a bunch of psychiatrists and told them that there was no data for the use of Lamictal as an antidepressant or antimanic they would have condescendingly shaken their heads and told me that Charlie Nemeroff had just been there, and he said...

And if I challenged them to read the studies that I had brought with me to prove my point, they would have told me that of course these were only a select sample of studies, there were other studies showing that it was an antidepressant... and I'd say where? and they'd say well... and I'd say what? and someone would inevitably roll out the "if this is true, how come other [smarter than you] people haven't said anything? And it would all degenerate into the DMZ of "well, my clinical experience has been..."

I have managed to publish quite a few papers; but when I tried to publish papers critical of the existing Guidelines--I had experiences quite similar to Ghaemi's:

The paper wasimmediately rejected by one of the editors in July 2006, withoutcomment. I asked for specific feedback, and received a letterwith numerous complaints, such as what follows: "There is aconsiderable literature on this specific topic, almost all ofwhich you failed to cite". The editor goes on to note that someof these papers were co-written by the editor, which had "profoundeffects". He continued: "This failure on your part indicatesa naivety [sic] or ignorance of the broader picture....You thusfail entirely to give the paper context...As a psychiatrist,you will appreciate the annoyance any JAMA editor might naturallyfeel when the manuscript he reads has an abstract written inthe New England Journal of Medicine style..." He dismissed the abstract as "classic...prettymuch useless," the methods as "wandering and discursive," theresults as "incomplete ... trivial...If you had sent us a crisp paper that clearlystated a hypothesis, and a credible way of investigating it;if you'd given us the context, clear methods and adequatestatistical analysis; if you had provided the relevant citations,and if your hypothesis and investigation had been on somethingthat hadn't been already documented by others: then wemight have been interested. Unhappily, you did not. I hope thiswill help you in the future. Best wishes."
Here's what you don't know about peer review: it's really peer pressure.

IV.

I have been too hard on psychiatrists who thought Lamictal was an antidepressant, or even a mood stabilizer. They were-- pushed-- into thinking it. If you only read the abstracts:

Conclusions Both lamotrigine and lithium were superiorto placebo for the prevention of relapse or recurrence of moodepisodes in patients with bipolar I disorder who had recentlyexperienced a manic or hypomanic episode. The results indicatethat lamotrigine is an effective, well-tolerated maintenancetreatment for bipolar disorder, particularly for prophylaxisof depression.
it's possible you might have misunderstood the paper and thought it was good for everything. Hmm. Maybe the peer reviewers missed that.

V.

Ghaemi has an optimistic bias: "had we known of these, we would have acted." No, not in this generation's psychiatry. If the overuse of Lamictal was due to hiding negative studies, does he think its rapid decline in the past two years has been due to the release of these studies? Did we stop using Depakote because we all finally read the article from 2000?

They went generic. That's all. And it's not the absence of reps that made docs forget about these drugs; it's the absence of "studies" and reviews in all the journals telling us, over and over, to use them.

The problem of psychiatry isn't the hiding of negative studies-- even if they were available, it would make no difference, because we're not prescribing based on science, we're prescribing-- like Ghaemi's colleague-- on word of mouth. Psychiatry is politics, and we basically toe the party line, no matter what common sense, logic, or even science tell us.

Americans learn their civics from the TV news; psychiatrists learn their psychiatry from their newspeople, too. Those people are called thought leaders, and they have far more power to drive practice than any amount of data, hidden or not.

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===== ====== ===== The Last Psychiatrist: Update on Schering Plough
It started with the Vytorin study, and my belief that doctors purposely misstated the results in order to support/portray an anti-Pharma bias. The stock tanked, but I predicted that eventually reality would set in, and so the American College of Cardiology was giving me the opportunity to make 20%.

Technically, it was only 18%, but I'll take it. Sold today. Likely goes to 20, but I only bought it to prove a point: doctors, especially in committees, cannot be trusted with their own data, and politics always wins over science.   I was able to make money on the politics, but what about the patients who are pawns in this game, who think they're getting "evidence based" care?

Good luck, everyone. You'll need it.

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===== ====== ===== The Last Psychiatrist: Upgrading Movable Type Is Like Getting Hit By A Bus While Watching An Airplane Crash
You think I'm kidding?

You may have noticed that for the past week, there haven't been any new posts and new comments weren't being accepted. That's because the site was up while the blog engine-- Movable Type-- had detonated itself.

The problem is that upgrading Movable Type requires a level of technical sophistication that seems ridiculous to expect of anyone. Movable Type comes with these handy instructions:

Make a backup of your database - Whenever you are making a change to your system such as this, it is always considered wise to make a backup of your data just in case you need to undo anything you might have done.
Download Movable Type 4.0 - Once you have backed up your system, download Movable Type to your web server.
Unzip Movable Type - Using your preferred unzipping software, unpack the Movable Type archive onto your file system.
Copy Movable Type's Files Over Your Old Installation - Copy all of Movable Type 4.0's files over your old installation of Movable Type.
Consult "Important Changes You May Need to Make" - In this guide you will find a section devoted to a list of things that everyone upgrading should be aware of. Read this section carefully and make any changes applicable to you.
Login to Movable Type.

While these instructions are typed and have correct punctuation, they do not actually prepare the average user to perform an upgrade. Do you know what the server name for MySQL database is? Exactly. Turns out it isn't "localhost," which is weird because that's what Movable Type defaults into the entry box.

The answer, as it happens, is "mysql" which seems shamefully obvious in retrospect. The 'obvious' part is in retrospect; the 'shamefully' part is every time you interact with support people.

Can anyone tell me why I can install Windows Microsoft Office with one or two obvious mouse clicks, but upgrading Movable Type requires me to ftp then chmod the following 14 files:

oh, wait, you don't know what chmod is, either.

Before the slashdot crowd hurl Diet Cokes at me, let me point out that this software is supposed to be for bloggers. That includes the 14 year old who writes the blog I Like Rainy Days, a delightful pink blog with bunnies I just made up. What, she doesn't deserve to use Movable Type? She has to stay on MySpace? This is the wold's biggest problem with software designers: they understand functionality, but not usability. Programmers are particularly proud of-- insistent on-- clean, well written code. That's awesome, really, except I can't see the code. What I see is an error message, which I'll admit is clean and well written. There's a reason the iPod is doing so well relative to the Zune, even though the Zune is arguably a superior product. And it isn't just because it's white. Well, not completely because it's white.

Movable Type is a product, right? You want customers, right? Or are all Movable Type blogs supposed to be about Movable Type?

I once felt an aesthetic and intellectual responsibility to install Linux on my new computer. The result was that my computer committed suicide. Seriously. Right there, in front of me. It plugged itself in and jumped into a bathtub full of water and pulled in a hair dryer as well, for good measure. Do you know how much better Linux is than Windows? Well, neither do I.

Software complexity of this type necessitates some kind of user support system. Too bad. Movable Type support prefers to communicate using form letters.

Yahoo!, my web hosting service, was actually worse. It was so much worse that it's comical, bathtub-computer-dryer comical. Ultimately I had to contact Yahoo! on the phone. Think about this.

The second guy I spoke with-- immediately after I hung up with the first guy-- told me there was no solution to my problem, that I could not upgrade, I could not restore my backup-- because, even though I made a backup which I was at that moment looking at, that backup wasn't actually made, it was only scheduled to be made-- and that all my data-- old blog posts, comments, etc-- was lost. Got that? Me: "but I can see it, I'm in the directory, I can download a file, I can read a post, the stuff is there." No, he assured me, it wasn't. "But I can read--" No. I guess if I knew Perl, I'd understand.

The reason I called the second guy in the first place was that the first guy I called referred to "Movable Type" as "Wordpress" which I'm pretty sure is not correct.

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===== ====== ===== The Last Psychiatrist: USAToday Says Drug Ads Are Smarter Than Doctors

There's an article in USA Today which says, essentially, that drug ads cause patients to ask for medications which they don't need, which are then given to them by their doctors. The key is that the doctors would not have given them these or any medications had the patient not asked.

The first question that can be asked is, ok, sure-- ads make patients ask for these medications. Why are the doctors succumbing to this pressure? It's a loaded concept, and I'm confident USA TODAY hasn't thought it through: are you suggesting that the doctors are prescribing a medication which is not indicated for the problem the patient describes? Or are you saying the doctor is a moron and doesn't think to recommend it in the first place? Or, are you saying the medicine isn't really needed, but the doctor is pressured to give it anyway?

Which brings us to our semiotics lesson for today: what do we mean be "need?"

I.

The article's secondary point is that the ads drive up medication spending. Wrong: doctors do. If medication spending goes up, its because doctors are prescribing more. Leaving aside the appropriateness of this prescribing, if you want to reduce costs, you target the doctors.

The point is that the doctors' prescribing shouldn't be so fickle and malleable that it responds to either ad pressures or, in this case, removing ad pressures. If the only reason you gave the Nexium for reflux is that the patient pressured you into it after seeing an ad, then the ad has more power over you than the existence of the condition. The problem isn't the ad.

Let me clarify: if you notice reflux and give Nexium, that's fine. But if you didn't notice the reflux at all; or see the reflux and don't give Nexium-- but then sometime later give it because the patient asks for it, you're fired. The ad was smarter than you.

II.

It's a logically inconsistent to say "doctors prescribe drugs people don't need" and also "people can't afford their medications." Perhaps they don't need the drugs they can't afford?

What these articles are unable to state clearly is the idea that medications can be valued differently-- blood pressure med more valuable than reflux med-- but that price is no longer a reflection of this value.

Why not? Well, price controls and 3^rd party payers, thank you very much Comrade. There's no incentive for Pharma to reduce prices, and no economic incentive for the doctor or the patient not to take more pills. Why not add Nexium? No reason not to. So Nexium becomes priced like tamoxifen-- in some cases, is more expensive than tamoxifen, even though it is less valuable.

III.

So, bottom line, you want the doctor to use the medication "budget" intelligently. Ok. Here's the solution: give the doctor control of the pharmacy budget: every patient gets $20/day. Go.

Prices will fall. Pharma will be incentivized to create drugs people need, as opposed to yet another Viagra. Subspecialists will confer with one another to decide what's needed and what isn't. No more Zyprexa + Lipitor. Get it?

Doctors hate this, because it's another thing they have to worry about, along with drug-drug interactions, side effects etc. Well, if they were actually worrying about these things in the first place we'd have some room to argue. I think it's tremendously awesome that doctors, the AMA, the NEJM spend journal space on the government's position on torture and gay rights. How about saving some pages for pharmacology and economics?

Bottom line: someone has to be accountable. It makes no sense to have the spender of the money be separated from the money itself. Under the guild system of medicine, doctors have to be in charge.

IV.

Adding Nexium to a tamoxifen script increases the total expenditure on meds, but it does not drive up the price of tamoxifen. You "need" tamoxifen, so you pay for it; but you could forgo the Nexium.

The problem is that in many cases, the patient could not possibly make these value distinctions. The presence/absence of generics complicates it further (brand Actos for diabetes, or two generics for blood pressure?)

Which is why, again, it falls to doctors. But to make these value calculations, they must hold the wallet.

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===== ====== ===== The Last Psychiatrist: Vanderbilt University: The Goal Is To Keep Them In Puberty, Part 2
Time Magazine's A Frosh New Start describes Vanderbilt University's $150M public works project to create an all/every freshman 10 dorm "Commons" where-- if I read this right-- they "will help first-years get acclimated to college life."

I suppose it occurred to no one that the "college life" these first-years are getting acclimated to is exactly the kind of artificial world of the Commons?

But it's not just for freshmen, it will also house 10 professors and a "Dean" who will live there. Yes, some of the professors have families.

Someone will say, "but what's wrong with that? Why not segregate them a little, hell, even coddle them a little, in a highly intellectual environment where they can focus on their studies without the outside distractions?"

And what would those outside distractions be? One year later, those freshman will have theoretically benefited mightily from this experience, and move on to be sophomores. Why would the next generation of freshman need to be walled off from them? Why are sophomores a distraction to freshman? Put another way: what possible distraction could sophomores-- older, theoretically wiser-- be that other freshman are not already, but worse?

What does anyone expect freshman to learn from other freshmen-- and ten professors? If you want them to develop, shouldn't they be living, ideally, with people who can elevate them, or at least away from other freshmen?

The goal is a living-and-learning environment that promotes both school spirit and responsibility to community among an increasingly diverse student body.
Really. I'm not really a soldier in the culture wars, but could every one of those words be any less the purpose of a college education?

One might legitimately ask what possible role in-dorm professors could have. It's pretty hard for me to believe that 1500 freshmen are going to skip American Idol to go hang out with their (ten) professors-- unless their professors are watching American Idol.

"A very small percentage of students see me as a father figure, but I try to discourage that," says sociologist Tony Brown
But setting kids up in an idyllic environment where they have no responsibilities except their school work and who have ten people acting as "guides" doesn't sound much like discouraging being seen as a father figure. Or do you have another method?

who opens his dorm apartment on Friday evenings for rap sessions, using bait like cookies, Wii Tennis and his pet rabbit.
Tremendous.

Don't blame the kids outright. Always blame the parents, always, not because they are "ultimately responsible" but because they are the ones that set this up on purpose, a ten dorm extension of The Village.

"At move-in, I can't tell you how many parents said to me, 'Oh, good, you're an adult. Please take care of my kid!' But this was sold to us as an academic endeavor," [says a professor.]
Maybe the Wii Tennis sent the wrong message. Maybe the Glass Bead Game would have been better.

It doesn't stop with freshmen.

Vanderbilt has a $1.75 billion capital campaign to turn all the rest of its dorms into neighborhoods where some 5,000 upperclassmen and their professors can live and eat together... [Says] Michael McLendon, who teaches public policy and higher education at Vanderbilt. "Now we want to make sure their education is social."
Why, again?

-----

Part 1 here.
Part 2 here. (You're reading it.)
Part 3 here.

Don't forget about Diggs, Reddits and donations. Don't make me run a pledge drive.

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===== ====== ===== The Last Psychiatrist: Violence Intervention Program
What does the government want to be true?

From CNN:

[Associate professor of surgery] Cooper created the Violence Intervention Program (VIP) at the Shock Trauma Unit of the University of Maryland Medical Center, the state's busiest hospital for violent injuries. It became one of the country's first hospital-based anti-violence programs.
"We approached this problem like any public health crisis, like heart disease or smoking," he said. "We tried to work on the root causes."
Since 1998, VIP has provided substance abuse counseling, job skills training and other support services to nearly 500 trauma victims.
A 2006 study by Cooper and his colleagues, published in the Journal of Trauma, showed that people in the program were six times less likely to be readmitted with a violent injury and three times less likely to be arrested for a violent crime.

Six times? Ok, so I'm in. This is a program which speaks to my personal biases: social problems solved by social methods. You take a group of people who got shot, stabbed, and help them "get out of the game" (their words.)
No one here got diagnosed bipolar, no one was put on Depakote. Some hands-on intervention by a support team, and boom-- people die less often (and are jailed less often.) Sounds like an innovative program with solid efficacy data. Sign me up.
Oh, wait...
I.
Why does it work?

One might surmise that the fact that Dr. Cooper is black might have something to do with it, perhaps by encouraging more positive transference from the trauma victims. But how long does he spend with them ,really? Milliseconds? Yes, his race may be helpful; but no it wouldn't be enough to explain a six fold reduction in violence.
It is, however, undoubtedly the only reason CNN chose to report on this program, and not any of the dozen others I found searching the internet.
So now the question becomes, why CNN? Why now?

II.
I had to review the actual study a few times to find the explanation, and yes, it saddened me.
The patients randomized to the intervention group then met with a social worker or case worker and a parole and probation officer assigned to the program. After the patient was discharged, the social worker or case worker and parole and probation officer met with the patient (now client) at scheduled intervals. Home visits were also performed by members of the VIP team.
The control group received no organized support from the VIP team and continued with the parole and probation agent who was previously handling their case.

These victims were all supposed to be on probation/parole. What's changed is that now they are going to see new probation/parole officers who are actually going to do their job, regularly, and someone will be coming to the house to check on the parolees. Victims. I mean victims.
In other words, they're now on probation/parole.
The program doesn't represent an innovative way of decreasing violence; it represents a failure of the regular system, that doesn't monitor anyone, ever, except when it's convenient (e.g. they want a pretext for incarceration.)
III.

Two points. First, this represents another example of social policy being offloaded to medicine, for the usual reasons: medicine has more money than social programs do; it taps into the intellectual expertise of doctors, instead of police, etc.
You might say, well, what's wrong with all that? Nothing, nor am I saying the program shouldn't be implemented, but doing so avoids the question of why it has come to pass that it needs to be implemented; why are we fixing a broken social program by adding a new medical program, instead of fixing the broken social program? In other words, why not simply make probation more accountable, and save everyone the trouble and the cost?
Which brings me to the second point, the unspoken truth: the point of the programs is precisely the increased cost. It is wealth transfer; Dr. Cooper just employed two new probation officers, a social worker, etc, etc. I'm sure somewhere there's a billing code for it. The victims are poor people, so government money is involved.
One way or another, doctors are going to get paid. And social workers are going to get paid. And hospitals are going to get paid. And UNH and Wellpoint are going to get paid. And etc. If it means medicalizing crime and welfare and climate change and Darfur to do get at some of that government money, so be it.

IV.

No, no, no, I'm not saying the doctors are trying to suck money out of the government. I have no doubt that Dr. Cooper had the absolute noblest of intentions here, motivated entirely by a desire to help. I'm saying the government wants to give its money away, this is how it keeps the system running. You have the problem of black youth violence anyway, why not pay medicine to handle it? Keep doctors happy enough that they don't notice they get paid next to nothing for actual medical care; shift the focus away from "failure of society" to "biological underpinnings"; convert "misguided social programs" to "coordinated medical care to decrease the problem of youth violence" and prevent some riots? Everyone's a winner.

Like an idiot, I've been yelling about the encroachment of medicine into social policy, and now I think that's been the point all along.

---

I'm on twitter, if enough people sign up I'll try to make it worthwhile

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Violent Crime vs. Coffee vs. Wine

Draw your own conclusions.

Violent crime range: 1.2-2.0 million
coffee: 20.2-27.5 gallons

Wine range: 1.7-2.3 gallons

From http://www.swivel.com/graphs/show/1163271

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===== ====== ===== The Last Psychiatrist: Vioxx

Merck's previous win in the Vioxx suit gets thrown out because the judge was concerned about the new criticism of the NEJM study.
What happened is an idiot's guide to forensic computing. Greg Curfman, executive editor of NEJM, was going to give a deposition in the trial of Frederick Humeston, an Idaho postal worker (or he was just curious about the data after Vioxx was pulled-- depends on which story you read) and so pulled the manuscript. Back in 2000 you'd submit a paper copy and a disk; NEJM says they worked off paper, so the first time they looked at the disk was Oct 5, 2004 (days after Vioxx was withdrawn.)

Here's the fishy part: on the disk was a table called "CV events," which was blank.
Time stamps in the software indicated that the table was deleted two days before the manuscript was submitted to The New England Journal on May 18, 2000. "When you hover the cursor over the editing changes, the identity of the editor pops up, and it just says 'Merck,'" Curfman says.
What's so terribly misleading about this and NEJM's "Expression of Concern" is this statement:
We determined from a computerdiskette that some of these data were deleted from the VIGORmanuscript two days before it was initially submitted to theJournal on May 18, 2000.
This isn't true. First, the missing MIs were never in the table to begin with. Second, the table was deleted, but the data itself was still in the paper.

Now it is obvious the study attempts to minmize the thromboembolic risks. What do you expect from an academic study? Let me assure you-- if you think drug reps are biased, go find yourself a professor.   So I acknowledge the criticism that the study is misleading. But.

But it's the social policy angle that gets me, the moralistic high ground of journal editors who are far worse than study authors. The gateway to hell is peer reviewed.
The article says Curfman was deposed by plaintiff's lawyers. Was Curfman paid by them? It doesn't mean he's biased, but if you have to disclose Pharma sponsorship, don't you think you should disclose lawyer sponsorship? (and I am looking to find out if he was indeed paid.)
As I have absolutely no interest whatsoever in the actual outcome of these trials-- my interest is really about how doctors butcher science and promote themselves to senators-- but, we should take a look at what this revelatory missing data says.
What they found was that with the inclusion of the missing data, the rate of heart attacks would have been 5 times greater than naproxen, not 4 times. 0.5% vs. 0.1%.
Just to put this in perspective, of course, you should know that the missing data was three more heart attacks, raising the number of patients with MI from 17 to 20 (out of 4000+ patients), vs. 4 in tha naproxen group.
BTW, "five times" and "four times" may sound like big differences, but they do not even approach statistical significance in this study.
BTW, strokes were the same in both groups. Not that anyone cares, of course.

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===== ====== ===== The Last Psychiatrist: Vote

Hi. Vote for me for Best Medical Blog.
http://www.medgadget.com/2006bestmedical.php

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===== ====== ===== The Last Psychiatrist: Vytorin

The article that has infuriated everyone, that no one will read.

If you don't know: Schering-Plough funded a study between its drug Vytorin-- a combo of Zocor and Zetia, vs. Zocor alone.

The results were expected: the combo Vytorin reduced cholesterols and other parameters better than Zocor alone.

The other results were not expected: the combo was no better than single Zocor in preventing artery thickening.

SP tried to delay the results of the trial: cue righteous indignation everywhere.

The lead investigator's now famous emails:

This starts smelling like extending the publication for no other [than] political reasons and I cannot live with that.

and later:

you will be seen as a company that tries to hide something and I will be perceived as being in bed with you!

SP should not be able to delay the results (BTW, they are almost never able to do so.)

But absolutely no one wants to ask the more pressing question: why did anyone do this study in the first place?

Pay attention, and you will see why medicine will collapse if it continues this way.

There was already data that showed it lowered cholesterol better than statins alone-- and no one disputed that data.
Doctors already have the cognitive bias that two drugs must be better than one (though may have more side effects.)
Vytorin was already approved. It wasn't looking for a new indication. This would have been barely knew information even if it was positive: "It reduced intima thickening? Didn't we already kind of assume that?"

So the answer is, obviously: SP wanted new data to put in a shiny detail piece. Gotcha. But why would a team of doctors care to take on such a purposeless study?

Do you understand?

And another question: why this outcome? Why not the obvious one, reduction in mortality?

---

Before that can be answered, you have to understand that this story isn't about Vytorin, it's about Pharma and their evil, lying ways.   Never mind that they didn't lie, that the drug did exactly what it was said to do. It's the public's anti-Pharma backlash, acted out in emails and a cardiology conference.

For sure, they tried to delay the data's release. But look through the stories, the hostility is really about SP pushing Vytorin, period.

"Vytorin doesn't work." Wrong. "Vytorin isn't better than Zocor alone." Also false: it is better in several different ways (LDL, total cholesterol, CRP, etc.) What it was the same for was intima thickening.   Could it be that that single parameter is flawed?

Both drugs slowed the progression of intima thickening. To the same extent. Here's the problem: both drugs work by slowing the progression and reducing the existing size. In this study, the size was not reduced because the walls were already thin-- these are familial hypercholesterolemia patients who have already been on statins for decades-- this effect won't be present in them.

---

So if Vytorin is better than Zocor in several ways, but not for the outcome of intima thickening; and anyway that's hardly the outcome we want to know about-- why such a backlash?

And why would SP do this to itself? Why not do a study on mortality-- much more probably with a better result-- instead of a technically different study of a proxy for a proxy for mortality? (Intima thickening is measured because you can't see the tiny plaques themselves, so it is assumed that more thickening must mean more plaque, which must also mean more death.)

The answer is this: doctors don't care about mortality data. No, don't run away, listen. The game has never been about reducing mortality specifically-- otherwise a lot more people would be on lithium and a lot less on VPA-- or anything else, for that matter. And we'd prescribe nicotine gum much more often than Prozac. Etc.

The medicine game has always been about acute treatment, not chronic. (Psychiatrists get away with a focus on maintenance because they make their patients come in every one or two months.) Doctors don't focus on long term because of the perception that a million things could always go wrong, better to fix what's wrong now. And worse, acute treatments simply default into chronic treatments. Or a series of chronic acute treatments.

In short: for the first month of an illness, medicine is awesome. After that, we pretty much don't have a clue what we're doing.

---

And the reason for that isn't SP or anyone else. It's bias. Doctors are a collective existing for a higher purpose; but each individual doctor is a person, and that person has to eat; and he has to eat where his peers will acknoweldge him, value him. It's narcissism. Not selfishness; they're not greedy or spiteful or envious. They simply have an identity they need to validate; a career they need to promote, and by hell if intima thickening is going to get me a grant to pay for some of my academic salary, what's the harm?

I sympathize, I do. But the harm is that you've just pissed your life away on another treatment parameter that isn't necessary, while overall life expectancy-- flatlines.

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===== ====== ===== The Last Psychiatrist: Wakefield And The Autism Fraud-- The Other Part Of The Story

get it?

Does the MMR vaccine cause autism? Merely writing those words guarantees the google crawler is going to summon the trolls. But it's a legitimate question, not legitimate in that it is true but legitimate in that since someone says it does, we should all be interested in finding out one way or another.

Short version: a paper in 1998 with more authors than test subjects observes that previously normal kids developed autism after the MMR vaccine. Back and forth, the science is questioned, 10 of the authors renounce the study and Lancet ultimately retracts the study.

However, a new analysis finds that Wakefield wasn't just wrong, but he probably faked the study.

From AP:

The analysis [by Deer] found that despite the claim in Wakefield's paper that the 12 children studied were normal until they had the MMR shot, five had previously documented developmental problems. Deer also found that all the cases were somehow misrepresented when he compared data from medical records and the children's parents.
The obvious outrage is how this guy frauded all of us, and may have inadvertently/on purpose caused thousands of kids to not get the MMR vaccine.

But there are two other problems that should also generate outrage, or at least bafflement.

First, it's 2011. The paper was written in 1998. How long does it take to look over the primary source data?

Which brings us to the next, larger problem: the people who finally reviewed Wakefield's paper, scrutinized the primary sources, and went and talked to the parents was not a team of neurologists or 3 new peer reviewers, but a journalist.

That's who we have fact checking our science.

This journalist did what all of medicine did not do for a decade: email 12 people.

II.

Hold on: as we now already knew for years, Wakefield wrote this paper in order to support a lawsuit against the vaccine manufacturers. In 1998. There were several other Illness v. Vaccine civil cases as well.

No?

Let me spell it out for you: in these gigantic cases with millions of dollars at stake and every possible resource imaginable-- Wakefield himself got $500k-- no one in the legal community thought to verify the science either. They just trusted the expert witnesses, who, of course, never read a primary source on anything-- always review articles and books. All that money hinging on, essentially, the word of Wakefield, and no one bothered to check his work.

Think about this when you meet with your public defender.

III.

I get it: Wakefield's evil. A Big Legal shill who faked the data to enhance his testimony and own profits. He probably thought-- and this is in fact what happened-- that it would be a small enough study that no doctor would care about it, but he could use it in court to say "there is evidence to support the notion that..." And, indeed, no one read that paper until 2 years later, when Wakefield pressed his luck by writing more articles citing that study.

We should "extradite him to Britain to face fraud charges," said some article somewhere.

Whatever. If you want to be cattle and moo with the herd, fine: blame Wakefield. But Wakefield didn't do this, Wakefield is a product of this. It's like blaming Bernie Madoff for the banking crisis. He's guilty, but he isn't the cause of the problem, he's the result of the problem.

You scientists have created a system that trusts, implicitly, the word of every scientist-- except if he is getting paid by Pharma, of course (as everyone knows, NIH and university funds do not influence results.) If he says the patient had a -7 on a scale, then it was -7, end of story. "Well, we have to trust the researcher a little bit, otherwise the whole architecture falls apart." Exactly. Why then do you not trust bankers that way? If a banker lies he goes to jail. Are there any penalties for making up a study? Do you seriously believe that scientists have less reason to nudge the numbers than bankers do?

Then, you'll engage in serious academic disputes about whether MMRM is better than LOCF for analyzing a double blind study-- you'll assert that double blind trials are the gold standard!- when you all know that 75% of the time we can tell if it's placebo or drug. When you title the paper, "A Double Blind, Placebo Controlled Trial of---" you are lying.

And why wouldn't you? The system is set up for you to lie.

Why, in the internet age, is the primary data not part of the paper?

Peer Review is a joke-- why do you call it that? They're not my peers, they're my close friends or my mortal enemies depending on my/my department's relationship with the editor; and they're not reviewing it, they're writing asinine, self-important comments that will never be noted after publication.

Why doesn't it change? The answer is precisely in what Wakefield did: he wrote a tiny paper that he hoped would not be scrutinized (or even read.) He just wanted to be able to say he wrote it, he wrote it not for science but for himself. Now pick up any journal. How many articles within are not for clinicians to act on, they're to put on a CV, get a promotion, get a grant, establish a name. That's why we have ten million journals, none of which anyone reads, ever.

Fortunately enough good science gets done, loudly, powerfully, that medicine moves forward. But the amazement shouldn't be that Wakefield's study was a fraud, the amazement should be why we haven't discovered hundreds of studies that are frauds.

I'll save you the meta-analysis: it's because we don't have enough journalists.

----

From 2009:

MMR Vaccine Finally Cleared Of Assault

Autism And The MMR Vaccine: Bait And Switch, For Profit

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===== ====== ===== The Last Psychiatrist: Wanted, Starring Angelina Jolie, Is The Greatest Movie Of Our Generation

And if you dispute that, I am coming over to your house, pants down and guns blazing.

If this looks like the kind of movie you'd like, then you're in luck, it delivers.

If it doesn't look like anything you'd ever like, then you probably want to buy a copy of The Women, a movie so dangerously vacuous it carries a Black Box Warning for Suicidality in Children and Adolescents. It's the movie Mick Jagger would produce if he he simultaneously hit male menopause and a truckload of opaku dung and then got down to producing, which, believe it or not, is almost exactly what happened, except that it wasn't male menopause.

The best thing that can happen to you while watching The Women is cataracts.

AREN'T YOU BEING JUST A TAD JUDGMENTAL?

No.

SO WHY IS WANTED SO GOOD? IS ANGELINA JOLIE NAKED IN IT?

Well, no, not really. There's a brief shot of her from the back getting out of a bathtub, but she is so heavily tattooed that she looks like Venom got her.

WHAT?

Hey, if you don't like the reference go back to The Women.

SO WHAT MAKES THIS MOVIE SO GOOD?

I didn't say it was good, I said it was GREAT. It contains all the elements a pathologically narcissistic and emasculated generation of men need to make themselves feel good again, without marijuana OR facebook. Let's review:

1. Subtext: "You are special."

By "subtext," I of course mean "subtitle." While to the great unwashed it appears that you are a lowly account manager in a cubicle with a cheating girlfriend and no self-respect, in fact you are much, much more than that, like, for example, a mystical assassin with the ability to shoot curveball bullets.

Importantly, your specialness comes not from effort, work, emotion, intellect, perseverance, or concentration, but from just being you-- in this case, being from the lineage of a 1000 years of special people. All you had to do is get born! Thanks feudalism!

2. Campbell/Lucas mythology of the heroic son unaware of his special lineage

You know how your Dad sucks? Well, he's not really your Dad. Your real Dad was a great hero, not an HVAC repairman, didn't your mother tell you? His sword is out back under a rock.

In this movie, he was a child when his Dad left (to be a mystical assassin) but, keeping to the mythology, was closely but secretly monitoring his son's development (in this case by moving in across the street and buying a telescope.)

3. Genetics is an untapped endless reservoir of possibility.

You know how you suck? Turns out it's genetic, but don't Mapquest cyanide plants just yet. Once you unlock your genes, you'll be able to do almost anything, including but not limited to shooting curveball bullets and slowing down time. I know, it's far in the future. But until then you can keep yourself from a suicide/pregnancy pact by remaining optimistic: the best scientists in the secret labs of Asia are working on it. In the meantime, why not test out your awesomeness by wrestling pumas?

4. Hot woman with amazing special talents and abilities chooses you.

Awesome. The Fifth Element, Alias, Ultraviolet, Underworld, Resident Evil-- all these movies represent the demasculinization of a decade of twenty-somethings, but lacked the most important element: you. This was fixed with Wanted. Angelina Jolie has all the necessary special powers and abilities, yet she chose you.

Back in the day-- e.g. the six thousand years preceding 1992-- the man had to earn the girl's interest/love/vagina by doing something extraordinary, or at least trying to be extraordinary, or at least being a good person, or at least paying her. Now, thanks to a lifetime of Captain Crunch, Coldplay, and institutionalized narcissism, a man can hope that a woman with special powers will want him precisely because these special powers allow her to see how awesome he really is. Not what he is now, of course, but, you know, what he really is. You know. Look past the XBox, you damn bitch.

Key point: even if he doesn't ultimately live up to his potential, he still got to make out with her. Nice!

5. You get to kill people.

Awesome, again. You know, back in the day (see above) all special abilities were to be used for saving people, and killing was always the last resort, and only to be done under the specific direction of John Woo or one of the remaining Wachowski Brothers. As the Bible teaches us, it's not murder if you're doing a back flip.

If a man doth close both eyes, and raise both guns, so does his aim grow more true.-- Galat 25:3

But in this movie, killing is the point. Never mind that there's no evidence that the targets are actually bad people-- that's a decision that Fate makes. Not metaphorically, I mean literally Fate makes it, and it lets you know by sending you a message in binary code written by a... magic loom. Look, if Angelina Jolie is going to like you, some people are going to need to die to balance out the universe.

6. Hot chick who saves you also kills people.

Madonna, whore and death instinct, all in high def! Thanks Freud!

7. Mystical manmade machines.

If your iPhone suddenly sends you a message in a binary code that says you need to kill John Smith, you're going to think back if you took your Zyprexa. Why? Because no one tells an iPhone owner what to do except Steve Jobs, got it?

But if something with no technology in it at all-- say, a loom-- tells you you need to kill John Smith, you have no choice but to pull up your pants and get your Sig Sauer. It's totally logical that God can influence a loom-- been doing that since Arachne-- but clearly He's too old to understand all that new fangled technology. The last time He did was in Stephen King's Processor of the Gods, which, if I'm not mistaken, was an IBM PC. Look, he's writing out the Book Of Names by hand.

What does it say about our time when we are more in awe of mechanical objects then we are of technology that uses quantum mechanics to operate?

8. You get to yell "FACE" to your ex-girlfriend.

I did have one question. If Wesley is such a loser before he learns of his specialness, how did he manage to get this girl as a girlfriend in the first place?



I'd like to see that movie, please.

That aside-- and maybe I'm different-- but if I was able to bend space and time at will, and I learned I was the first lieutenant of Fate itself, and it was my responsibility to emotionlessly execute specific human beings in order to restore balance to the universe, then obviously I'm definitely going to want to find my ex-girlfriend and show her what she missed out on, right? Why else even have those powers? Does that make me a bad person?

9. Breaking the Fourth Wall.

Nothing in a movie speaks to a viewer more than actually speaking to a viewer, and that's what this movie does. As it ends, Wesley looks up from his rifle scope, turns to the camera and asks, "This is me taking back control of my life. What the fuck have you done lately?" Well? "Not killing people" is, of course, a loser's answer, so don't pick it. Correct answers include, "waiting for my powers to kick in" and "not learning jujitsu because I'll be handed those skills all at once when they are necessary" and "waiting for Angelina to swing buy with a pizza" and "masturbating."

===== ====== ===== The Last Psychiatrist: Was Brontosaurus A Herbivore?

I.

1a. George Washington is the father of our country, the Revolutionary War general who helped free the colonies from their British rule. In what country was George Washington born?

2a. What modern animal is most genetically similar to a triceratops?

3a. T or F: The majority of the available scientific evidence strongly suggests that nicotine increases the risk of cancer.

4a. Your best friend in the whole world, Tom, sends you a letter which begins with the first two lines of Richard III: "Now is the winter of our discontent..." That's bad, right?

5a. Galileo, the scientist famously remembered by his first name, invented the 3x telescope. What, if anything, was going on in America at the same time?

II.

1b. Could someone born in another country become President of the US?

2b. Does a rhinoceros lay eggs or have live young?

3b. Do nicotine gum and patches have the surgeon general's warning?

4b. Does Tom like Shakespeare?

5b. What was Galileo accused of?

III.

Why did the b questions help you answer the a questions? Because they made you think from a different angle. You were first trying to remember the answer, but then trying to deduce the answer.

These questions should have been the stuff of elementary school education, but somewhere between learning that Washington had wooden teeth and "brontosaurus ate plants" we missed lessons that could be applied.

What we were taught was facts. We were also taught never to question the facts. No one thinks a 7th grade textbook is wrong. The results of a study may be questioned, but the Introduction section isn't. What makes a statement in the Introduction true is that it is in the Introduction. And go look how often studies reference the Introduction of another study...

Unfortunately, even these facts, tested in exams and backed by certainty were wrong, but there was no public apology. No one ever says, "wow, we were wrong." They just move past it. Some of these facts ruined lives. For me, infuriatingly, some of these facts resulted in worse grades in high school. Do I get to go back and reapply to a better college?

Brontosaurus ate plants (there's no such thing as a brontosaurus)
introns "do nothing" (not: "we don't know what they do")
giraffes evolved long necks because it helped them reach higher leaves (the giraffe did it?)
Everyone thought the world was flat in Columbus's time
etc

By focusing on facts, we learned a way of thinking which is not generalizable to knowledge or useful for its application. Worse, the isolation of these facts outside of context makes it difficult for us to detect them as wrong.

Education is at the convenience of the educators.

God Wouldn't Have Made The Same Thing Twice For No Reason

Most people know that birds are the closest relative to most dinosaurs; and they definitely know that dinosaurs are reptiles, but they pick rhino-- a mammal-- anyway. A triceratops is closer to a snake than to a rhino; indeed, a rhino is closer to a unicorn than a triceratops and unicorns don't even exist. Similarly: an eel isn't a snake or a worm, it's a fish.

They learned about evolution wrong(ly.) For most people 1) evolution is about morphology and not genetics; 2) they don't believe evolution is a random, sometimes redundant and repeating process, but rather a process of refinement, of moving towards something better.

Do you know why they think that? Because they were taught that.

"Conventional Wisdom Is Wrong"

Everyone knows cigarettes are bad, and that they have nicotine. So perhaps it's not surprising that 70% of smokers think that nicotine increases the risk of cancer-- because that's the one the evil tobacco companies spiked the cigarette with.

In fact, out of the 60 carcinogens, tar, arsenic, lead and CO inhaled with each puff, nicotine is one of the few chemicals that doesn't cause lung cancer or heart disease.

But, be honest, break the fourth wall: reading this blog, you quickly reasoned that the mere fact that the question was asked suggests it's a trick. "Aha!" you may have figured. "Nicotine patches!" Which is fine; The Princeton Review actually formalizes this way of approaching the SAT test (e.g. for the first third of questions the obvious answer is correct; last third of questions, the obvious answer is always wrong...)

Now, you have never once in your life said to someone "nicotine causes cancer." But it is 100% certain that within the next 5 days, you will repeat this question to others, and teach them that nicotine doesn't cause cancer. Knowledge is rarely offered freely; debunking of conventional wisdom is shouted from the rooftops.

I'll repeat: you've never told someone that nicotine causes cancer, but it is certain that you will now tell people that it doesn't. Because it's cool.

Unfortunately, nicotine does increase the risk of cancer-- just not in the same way that other carcinogens do it. (It facilitates the development of lung cancer, and possible breast cancer.) The evidence for this is not substantial but it isn't inconsequential, either. So telling people it doesn't cause cancer-- the information you were motivated to disseminate-- is absolutely, and dangerously, wrong.

Science is no different. Is a 2000 calorie diet the same as a 2000 calorie diet?

Everyone Else Is So Wrong That You Can Never Be Right

Look at the "decimate" cartoon at the top. You know deci means ten and you never applied it. You follow the herd, the herd that used decimate in the comic book sense: "we will decimate our enemies!"

But because decimate has taken on the common usage 'kill a lot of", it's not actually wrong to use it that way; indeed, if you try to use it the other way, you will confuse people. So the meaning that is actually conveyed will depend on your audience, not on you. You don't get to decide what you meant.

Now is the winter of our discontent
Made glorious summer by this sun of York;

Line 1 sounds bad, but line 2 flips it: things that were bad have been made good by the king. So what does it mean in the letter you received, bad or good? What matters is what Tom thinks it means.

That requires you to know Tom. And requires Tom to assume you're going to think it means what he does, i.e. that he is not aware that it means different things to different people, even though it really only means one thing.

This is knowledge claimed by misuse, anyone who wants to be understood should simply steer clear of the word decimate and Richard III. Take a minute and you'll come up with a thousand other words and concepts that have been murdered by misinterpretation.

Expression affects thought. When there are restrictions on expression, there are restrictions on thought.

Compartmentalization of Information

Even if you didn't know that Washington was a 3rd generation American, you should have been able to reason that since all Presidents must be born in the U.S., Washington had to be born in the U.S. (1) You possessed all of the necessary information; but you could not apply it. It's not your fault.

Galileo lived around the 1600s, and was found suspect of heresy by the Inquisition for supporting heliocentricism-- in 1632. This made it a decade after the Jamestown Massacre and Plymouth Rock. Consider, therefore, that the Pilgrims had guns and still believed the sun went around the earth.

Consider that the Age of Exploration-- Magellan, Columbus, et al-- happened 100 years before Galileo-- with a wrong understanding of solar system and before the invention of the telescope.

It's a game you can play all day: King Arthur (500AD) was twice as far from the time of Leonardo Da Vinci (1500AD) than to Jesus; Jesus was 500 years closer to us than to the building of the Pyramid of Giza.

Learning famous dates is of no value if they can't be used to contextualize events. Which, of course, wasn't the point of learning them.

And by learning so many bits of disconnected factoids, you are fooled into thinking you know something.

The Solution To The Problem Of Useless Education:

Where did George Washington, Benjamin Franklin, and Abraham Lincoln go to college?

------------------

1. Actually, this isn't true. Article II of the Constitution says the President must be natural born or a citizen at the time of the adoption of the Constitution. But it's safe to assume if you had any trouble with this question, you didn't know about that caveat.

--------------

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===== ====== ===== The Last Psychiatrist: Wasted Billions In Iraq

even worse than that

In March 2004, the Corps of Engineers awarded a $40 million contract to global construction and engineering firm Parsons Corp. to design and build a prison for 3,600 inmates, along with educational and vocational facilities. Work was set to finish in November 2005.

But violence was escalating in the area, home to a volatile mix of Sunni and Shiite extremists. The project started six months late and continued to fall behind schedule, according to a report by the inspector general.

The U.S. government pulled the plug on Parsons in June 2006, citing "continued schedule slips and ... massive cost overruns," but later awarded three more contracts to other companies. Pasadena, Calif.-based Parsons said it did its best under difficult and violent circumstances.

Citing security concerns, the U.S. finally abandoned the project in June 2007 and handed over the unfinished facility to Iraq's Justice Ministry.

Wait a second:

but where are the projects?

and if:

then

did they get the money anyway?

---

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===== ====== ===== The Last Psychiatrist: We Are All Mercantilists Now

Marx was wrong: feudalism doesn't precede capitalism, it follows it. And after feudalism comes this:

Welcome to 1600.

The schizophrenization of America becomes revealed. Was America too laissez faire, which lead to the crisis? Or not enough, which lead to a bailout plan? The answer depends, in large part, on whether you think it's your money at stake.

Whether it is a good plan or a bad plan remains to be seen.   Indeed, it will never be known since we will never really know what would have happened had the other course been taken. If Depression is indeed averted, no one will thank Paulson. Or, if Depression comes, whether it could have been averted by the plan. So be it.

But is it socialism?

No.

II. What is mercantilism?

In a sentence, it is the belief that a country's strength is tied to how much money it can accumulate. In the heyday of British mercantilism, 1600-1776, it meant the accumulation of bullion; favoring exports over imports; keeping money within the nation, not sending it elsewhere. The money could be used to purchase commodities and fund armies-- which, in turn, helped bring money into the country.

Mercantilism was premised on the belief that there is a fixed quantity of wealth in the world, and everyone has to fight over it. Economics, it was felt, is a zero sum game; and since not everyone can win, it becomes acceptable that they don't.

State policies reflected this. "Free trade" meant "free trade for me." Protectionist tariffs and regulations; international treaties that solidified trade superiority. Colonies to sell the exports to. And a tight control over the means of shipping.

Mercantilism also exerted influence not just on commerce but on thought and culture. In order to maximize exports, it had to convince the populace that the export (or approved import) was necessary. In the late 1600s, calicoes, previously the cloth of the poor, became a sought after fashion necessity-- entirely because it was what was being imported. It wasn't sought after and therefore imported; it was imported and therefore sought after. Cleverly, British merchants made high profile gifts of the calicoes to prominent ladies; the nobility accumulated them; and then everyone had to have them. They went into clothes, furniture, drapes. Mercantilism had changed the aesthetic of the the entire nation-- the world.

Generally unimportant products took on gigantic importance, because the market convinced people they were important. Here's an example: Columbus accidentally discovered America because he was looking for spices.

Capitalism identifies a market and then tries to maximize profit within it. Mercantilism, by contrast, creates markets on purpose based on what it has to offer, and then controls those markets.

III. The Sudden Decline of Feudalism

What preceded British mercantilism? Feudalism-- local, feudal power rather than a centralized government; vague territorial boundaries; and ever changing racial and cultural characteristics. It was local, and fluid. But as the world "shrunk" (or got flat) it could not adequately provide for its people. Unemployment and poverty rose. Meanwhile, the opening of trade and improvement in travel offered greater opportunities than farming someone else's land.

States formed, over time, and absorbed the fiefdoms, removed the existing lords, consolidated the power, and served the interests of its domestic merchants and producers.

And so the rise of the nation-state; racially homogeneous, with rigid territorial boundaries; partly feudal but with a new quasi-class system of nobility, merchants, workers, and slaves.

IV. Wither American Feudalism?

As I have written before here and here, for some time in modern America, feudalism was the growing trend; but rather than lord-vassal, it was company-employee. Government's role was secondary and shrinking; companies provided income, healthcare and retirement benefits, and, more importantly, a sense of identity and belonging. The company provided protection in exchange for service.

Even two years ago, this was increasing. These company-lords become even more powerful as they merged and privatized, going off the public exchanges but still wielding massive influence.

But for this progression was suddenly diverted. Now, instead of companies going private, they are going government.

Who has the big money now? Sovereign wealth funds, of which, if/when the Paulson Plan is passed-- for it is inevitable, in some form-- the U.S. will become. In the past, there was a tug of war between private ownership and state ownership. Now, instead of outright nationalization of a program (e.g. Social Security) governments own financial stakes in businesses, in sectors-- and in themost important sector of all, the financial sector. The Chinese have this system firmly in place, but pretend it is "communism." Saudis as well. And now, soon, the U.S.

How does the U.S. government separate its foreign policy with its fiduciary responsibility to its shareholders, which is you? How does it separate its domestic policy from a revenue motive? It can't. They become one and the same.

If the complaint in the past was that government is too influenced by big business, how does this change when government is Big Business?

Put all this together with a growing protectionist sentiment, and you have our new economic model: mercantilism.

America can't move closer to socialism, if for no other reason than those in power are too young to remember what it really looks like and how to execute it; and with so much individual narcissism, no one could demote themselves so much to the state.

Such policies like the Paulson Plan appear socialist because the government seems highly involved in the control, in the regulation of an industry. But this is exclusively in the service of the business franchises that it controls. The analogy for todays events isn't The USSR or even France; it's the East India Trading Company; an independent, for profit, business arm of the state. It was nearly a monopoly. It could even command the military, as needed.(1)

Within the East India Trading Company's flag was the union Jack-- Britain's flag-- contained in the canton. Get it? Britain at the service of the Company; the Company for the benefit of Britain.

V. Predictions

Reducing current events to historical -isms is a fool's game, for drunks in a bar or political scientists with tenure-- played when there is no accountability for the opinion. It serves no purpose unless it can be used to make predictions. So here they are, linked to the key characteristics of the mercantilism of old. In general, the future holds increased protectionism, increased state control, increased classism, and the necessity of piracy.

1. Protectionism: Obvious. Look for more, not less. More tariffs; more treaties ensuring trade advantage. Not only will the movement be away from capitalism, but it will be considered obvious that capitalism is unworkable. More emphasis on "Free Trade," as it is subtly redefined to mean "ensuring domestic products are not undercut by unfair foreign advantage such as low labor costs, etc."

2. National self-sufficiency: despite the importance of trade, the nation state sought to free itself from outside imports.   Domestic agriculture and manufacturing subsidies; "energy independence." That means solar power, whether or not oil is expensive; increasing ethanol and agricultural subsidies.

3. Shipping: Most important to mercantilism was control of shipping. While it was impossible to control what other countries tried to produce or export, Britain could control how and if it made it to Britain. The Navigation Acts required that all imports to Britain or its colonies had to be done on British ships, or through British ports.(2) Thus, cheaper goods from other countries could not be obtained, or were taxed so heavily as to make them impossible to afford. So British West Indian sugar was cheaper to Americans than French West Indian sugar, but only because the actually cheaper French West Indian sugar was taxed so heavily.

That "shipping" is nowadays done on the internet. Look for the government or its business arms to try and regulate or even outright control it, and strongly discourage (read: tax) the use of non-domestic providers accordingly.

4. The rise of the nation-state: In the past this meant racial homogeneity, but this will be replaced by regional and cultural homogeneity. So Russia tries to reabsorb its former satellites; and America asserts its cultural identity by seemingly arbitrary emphasis on the use of English, stronger national boundaries; clearer divisions between American and "illegal immigrant" with accompanying restrictions (e.g. no driver's license, etc).

5. Stronger central government. That this is happening is indisputable.. More monitoring, but as this is mercantilism and not fascism, the monitoring is in the service of commerce, e.g. Google, credit cards over cash, etc. Surveillance is for the protection of the state which is at the service of commerce.

6. The primacy of the military: economic disputes become political; and political disputes are settled, ultimately, by guns. Look for corporations to have their own mercenary armies, or have ready access to America's. And look for more wars, with the cover story of protecting Americans, stopping genocide, etc.

7. Colonialism: rather than foreign nations being politically controlled, the control will be economic or cultural. The purpose of the British colonies was access to raw materials, and the creation of new markets for the mother country's products. So too will come the need to convince foreign peoples that they need what we have, and need us to extract what they have.

8. Slavery: slavery will not return, but the use of groups of people who will work for much less than the citizens will be necessary to maintain competitiveness. Different from capitalism, however, will be that these people are purposely blocked from rising in class or wealth. Moral justifications will be necessary, and of the form, "they're better off than they were."

9. Classism: unlike the boundariless possibilities of capitalism-- up or down-- mercantilism requires specific classes, especially a working class. In America, classism will supersede all other internal disparities, including racial. This suggests an Obama presidency and the replacing of interracial conflict with intraracial conflicts, along class lines.

10. Ban on luxury goods: Sumptuary laws, though generally ignored, rigidly defined types of products that could be owned, and by whom. The rationalization was that they prevented excess and waste and kept the money in the country, reinforced national pride and morals, and provided markers social class.    The modern twist: no goods are luxury goods. Cars, GPS, brand name clothes-- they are all "necessities." Waiting at the welfare office, applicants pass the time texting on Blackberrys.

It's not their fault. The economy specifies that these are not luxuries. They are lulled into low introductory rates, a free handset; no money down. Those $400 shoes only cost $15 a month. Forever.

In a truly capitalist system, one would have to aspire to aspirational goods. The system is short circuited-- one can afford those goods without actually possessing the status or wealth that ownership implies.

Mercantilism maintains dominance not by best serving a market, but by best serving a market it creates.

11. Exports and Domestic Production: An emphasis on making specialized products of high quality to maintain export superiority (e.g. specialty goods over spatulas; services over durable goods.)

12. Inflation: If wealth is hoarded in the U.S., at the expense of another nation, than the value of the wealth falls in the U.S. and rises in the other nation. Eventually, it will not be economically profitable to hoard wealth-- it will have more value abroad.

13. The end of mercantilism: when the end finally comes, as it must to all illogical economic systems, it will be replaced by what replaced it in 1776 with The Wealth Of Nations: capitalism, and the beginning of the next Industrial Revolution.

That's some of what can be expected, albeit it gradually, so that no one notices.

VI.

There's one more important development, too large to be discussed adequately here. The control over commerce, goods, and pricing meant that not everyone was able to get, or afford, what they wanted (or needed.) Simultaneously, the state itself had to compete against other states for markets and materials. This necessitated an underground economy and related class; a class so necessary to and intertwined with these untenable economic policies that they are celebrated even today: pirates. They were the logical and inevitable extension of controlled commerce; were extremely skilled, and often navigated the shipping lanes with more knowledge and flexibility than even the military. They worked for themselves, or they worked for the state, as the situation arose.

In the new world order, shipping is the internet; the goods are data.

Drink up, me hearties, yo ho.

------

1. though in this case rather than the Company lending money to the Treasury for exclusive trading rights, the Treasury lends it to the Company for a cut of the profits and taxes-- which is in turn in exchange for protection.

2. The Boston Tea Party was not about the tea being too expensive because of tariffs; it was because British Tea Act allowed the EITC to sell the tea without a tariff, and therefore cheaper than even American smugglers-- Samuel Adams, John Hancock, and others-- could sell it.

===== ====== ===== The Last Psychiatrist: We Are All Skyscrapers Now

which photo can you see?

On September 11, 2001 I was nowhere doing nothing while 2000 people were dying almost simultaneously.

A week later we had the Anthrax attacks, which, like the 9/11 attacks, have never been solved. Whoever the Antraxer was, he did manage to infect one of the 9/11 hijackers, and so he stands as the only person to have at least injured one of the terrorists.

That was also when we got the text scroll at the bottom of CNN and the definitive end of actionable information from CNN.

This is something I wrote a few weeks after 9/11. It is what it is. A lot has happened since.

If the TV is any guide, 9/11 is a dramatic miniseries about two buildings collapsing on firefighters, with the premiere being brought to us commercial free. Gotta build an audience.

There's enormous coverage, but no news. None of this is news, it is drama, portraits of courage and sadness. Last phone calls between loved ones, "the last time I saw him was when...", "when I saw the first Tower fall I..."

And firefighters. Lots of firefighters.   America wants its real life heroes unarmed and unthreatening.

Lots of sadness, but no anger. No one on TV is angry? The Towers didn't fall, they were kicked in the face. How many politicians do I have to watch cry on TV? STOP CRYING. I already know it's sad. Don't tell me we are resilient, don't tell me we'll go on, are there people worried they won't go on?    Show me the country has some men in it, show me that we aren't five year olds.

But we are. Cry on TV and people will think you're sensitive, but bang a fist on the podium and you're unstable. "He can't control his emotions." What?

According to the TV, the real events of 9/11 happened not on the 95th floor, but on the ground floor. I've been looking in the wrong place.

People tell me that this coverage isn't about the terrorists, it's about the aftermath, the victims; that there are other shows about the terrorists.

Separating shows this way fosters a separation between the cause and the effect; we are focusing only on the effect, because it is very hard for us to get our heads around the cause. In doing this we are repackaging this event into a natural disaster. Something that we have no power over, no way to prevent, but something that must by necessity bring us together in our grief and our loss, and something that we must get past. No sense in describing why earthquakes happen, so let's delve into the victims' stories.
Observe that the media has unilaterally decided that no American will ever again see the
images of the planes being slammed into the Towers. "Come on, you've seen it enough times, nothing to be gained from that. Here's a firefighter."

I'm told anger serves no useful purpose. But sadness isn't going to prevent this from happening again, sadness isn't going to restructure the planet so that people don't want to do these things. You might say anger won't either, but I'll take my chances.

They say the hijackers were armed only with box cutters. If that's true, that tells me a lot about how they perceive Americans: they expected no resistance. Not even from the pilots. Would they have brought boxcutters to El-Al or Aeroflot hijacking?

When Timothy Mcveigh and Terry Nichols blew up the OK City Federal building, the media went right for the throat,it wasn't a natural disaster but an violent attack to which we immediately ascribed blame. And they were free to speculate: right wingers, militias, neo-nazis. But 9/11 is different, we don't know what to do with it so we do nothing with it. Say "they attacked us" and then off to the victims. You know the names of both OKC bombers, but you can't name one hijacker other than Mohammed Atta, who is the designated ringleader because his is the only name we can pronounce.

We don't even know what to call the attacks, so we call it by its date: "9/11." Just another day that we'll remember where we were when.   "That was such a sad and scary day." Yeah.

"We are all Americans now," announced Le Monde, with no understanding at all. How can they sympathize with how we feel when we ourselves don't know what we feel? This attack happened because we're not all Americans, not even us Americans. Just a group of individuals now slowly distancing ourselves. "I mean, I sort of knew him, I'd seen him around and all, but we weren't close or anything..."

"We are all Americans" means to the writer at Le Monde: "we could be next." That's all he cares about. He's right on that count, I guess, dead right-- the next attack has to happen in a different country if it is to have global impact.

If Le Monde wanted accuracy, it would have announced that we are all skyscrapers now, each of us standing mightily and individually, who is taller? who is greater? Living in proximity but not in connection. Waiting to be knocked down.

And when it happens to someone, our explanations will really be about why it didn't happen to us: well, that skyscraper wasn't built right and that skyscraper was too tall, too proud. What happened to that skyscraper has nothing to do with me, I'm different, I'm better, and besides, why would anyone hate me?

Because you're a skyscraper, dummy.

When the towers fell and the pulverized remains of people who might have been your friends poured through the aerosolized into the streets of lower New York, what did you feel? Which did you blame, America or Israel? Oh, both. When someone asks you now about 9/11, do you answer "I am sad" or "I am angry"? Or do you externalize your answer and put it in the past tense, as if the emotion was something that came at you from the outside, "it was sad", or "I felt angry"? Are you not sad or angry anymore? How long did it take you to get over the worst attack on America in history? A day, a week? How long before "cooler heads prevailed"? Do you know people who you think "overreacted" to the slaughter of 3000 Americans? As others dance while the bodies are excavated in NYC, are you able to connect with the story? How do you dialogue?   Maybe you should cope on this for a while, until your cooler heads prevail. Go shopping. Have a nap.

I don't want to cope. I want to see the videos of the planes being flown into the Towers. If we allow ourselves to choose the path of sadness, then nothing has been accomplished, everyone died for nothing. It will have been nothing more than an earthquake.

I don't want to get past this. Nor do I want it to get past me.

---

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===== ====== ===== The Last Psychiatrist: We Have Breaking News: You Don't

a picture is worth a thousand words but a picture of a word is priceless

Video:
Michelle: Scott Wapner is our eye on the floor on the New York Stock Exchange. Scott.

Scott: Thanks Michelle, well, you said it, it's that 1042 level that has me concerned...

There he is, he's not CGI, he's not been digitally enhanced. He's a real person, telling us real facts.

Note the production. Michelle is in studio surrounded by monitors and newspeople and information. But she's turning it over to someone who is on location. This is a deeper level of truth, he'll have insights and information she/we won't have because he's there.
Listen to the noise; he's talking loudly over the bustle of the traders behind him. Raw info.

But what's he going to learn? 50-75% of trades are program trades. Does he speak Bachi? And it would be an easy thing to have him mic'd and filter out all the background noise. But the noise is necessary to the drama. It's background music.

Note how he keeps looking to his left, as if the S&P is over there having a sandwich. But the only thing over there is another monitor telling him the price. He has no more information than Michelle at the studio; which is to say, no more information than anyone else. In fact after 20 seconds, all he does is show pictures of charts, none of which are at, or are generated at, the NYSE.

"Over at the Nasdaq Market Site" it's even worse: the entire Nasdaq is electronic. The only guy making money at the Nasdaq market site is the reporter. His anchor could pull the quotes off Yahoo! Finance and it would be the same. In fact, those screens have less information than Yahoo! Finance. In the land of one eyed men, we're listening to a blind guy.

All of this isn't to deliver better information, it is to convince us that they have better information.

Scott Wapner doesn't know why the market went down, but, importantly, the structure of CNBC makes it is impossible that he could ever know. The simple truth is that in the short term, the market went down because the Machines wanted it to go down. If you want to know why they wanted it to go down, you'll have to ask them.

II.

This is the same setup one sees in ordinary news; an anchor leads a story, then hands it off to someone in a different location: closer to the truth. Sometimes, this on-location reporter will play a snippet of a prerecorded interview, e.g.
I'm John Roberts, live at Capitol Hill, and earlier today I had the chance to talk to Senator Hutchinson...
and then they play the interview. So what's the point of standing on Capitol Hill if the information you have is neither live nor from Capitol Hill?   Because you watched.

Sometimes they'll play a muffled audiotape, and because they are so helpful they will also write the transcript on the screen. This can always be recognized as a trick. The transcripted words draw your eye and concentration, so you see the words they want you to see, in their context, not in the original context. Imagine reading vs. hearing the voice message of a surfer dude charged with killing his girlfriend: "come on over, baby, this party is going to be killer..."

This is especially true when the audiotape is transcribed and the transcription is read by a reporter. When you see that on TV, flee the area, your soul is in peril.

IIIA.

Medical journals are CNN.
Everyone has access to published clinical trials. But nobody reads them, because there are review articles out there which summarize them. Note the direction of causality. Reviews don't serve a need, they create a market-- for themselves. That's also what the press does. I see you furrow your brow, "wait, what--?" Read it again.
Listen closely: since you at home have access to all the clinical trials, you could theoretically write a review article and publish it. But you can't. Only academics can. You may have written an excellent review article, but in order to publish it, you have no alternative but to enlist the help of an academic. That's the news, too. The only way to tell the world what you know and make it legitimate is it to tell Wolf Blitzer first.
Those reviews will get published in the same journals as the clinical trials themselves, giving them credibility. When I reference a paper, no one asks if I'm referencing a primary source or a review article. The existence of the reference is its own proof of validity and objectivity.
No one ever says, "The Telegraph says, 'Societe Generale says, 'prepare for a collapse.' ' " They say, "Societe Generale says prepare for a collapse." Oh, I didn't know you were tight. Can you have them call me?
1.
Aside: even Societe Generale does not correct the Telegraph.
2.
No, sorry, yet another typo-- of course I didn't mean "Aside:" I meant to type: "What could be the significance of Novartis not correcting the media's description of the swine flu? But:"
IIIB.

Sometimes a review article will include a quote or a table from a primary source, just like a news team does.

Bad enough: you don't look up the quote or the table. Worse, the purpose of the quote or table isn't to enhance your understanding of the material but to give credibility to the review. It makes you think that you are seeing a deeper truth; the review has layers to it, the review level and the primary source level. You have two levels of truth on those pages.

Never mind you could simply read that reality yourself and skip the review level, which is, essentially, one nut's opinion, unchecked by anyone, positioned as truth. But the presence of that table guarantees you will not do this ever again. "This review is comprehensive and extensively referenced." That's true.
IV.
Medical journals are rarely accused of ideological bias, they are accused of financial bias. The press are rarely accused of financial bias, they are accused of ideological bias. If you studiously spend one month looking for the opposite bias in both, what will happen is that you will become an alcoholic.
V.
"Let's get down to our eye on the floor of the NYSE, where we have some breaking news." But aren't the barbarians in Greenwich?

---

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===== ====== ===== The Last Psychiatrist: Werther Effect: Copycat Suicides May Not Exist

Goethe's popular comic book, Sorrows of Young Werther, published in 1774, allegedly inspired two imitations; many young men decided to kill themselves, and many, many young men decided to dress in yellow pants and blue jackets.
Well, that's all great, but I decded to investigate whether suicide rates really do increase after one is popularized-- a propos of the previous post's discussion about whether Lott's roommate's suicide pushed Lott towards it as well. I was pretty sure it existed, but I may have been wrong. Preliminarily, here's what I found, through 4 examples:
A study in Austria found that gun suicides increased in the three weeks following a famous gun suicide (as compared to the three weeks preceding).   There are lots of this kind of study, which are correlations based on statistical anomalies.
A better kind of study actually interviewed the suicide attempters to see what had affected them. For example, a U.S. study found that exposure to parental suicide was not associated with suicide; exposure to a friend or acquaintance's suicide was mildly protective, and media accounts were strongly protective.    However, this study wasn't about the immediate risk (e.g. in the following month), and the authors did note that this protective effect was only if the friend's suicide or media report was greater than a year in the past. It is easy to speculate that the longer you have to think about what they did, the more likely you are to think it wasn't the best option.
A 1993 study in adolescents found that within one month of the suicide of a friend, depression and suicidal ideation increased; but actual suicide attempts did not.
Most of the studies finding no correlation are done using the general population; how would it be different if we looked only at people with established mental illnesses? A 2005 study found that suicides in mental illness patients were clustered in terms of place, time, and method. Unfortunately, this study looked at the clusters and did not identify whether or not the victims were actually even known-- or whether the patients had even heard about the suicides.    (For example, they might happen at the same clinic, but that doesn't mean they knewabout each other.)
Etc, etc. So clustering, at least in terms of lethal attempts, appears not to happen much, (and if it does it is primarily in teens.)
As an observation, most of the articles finding Werther effects were written pre 1980, while most finding no relationship were written post 2000. One explanation is that we are more rigorous now (HA!); the other explanation being that there is considerably less idealization of suicide now. In fact, suicide now is unremarkable. Consider the "medicalization" of depression and suicide, as biological diseases rather than character pathology or expressions of emotion, a communication of sorts.   Suicides then "meant" something-- something more than "I'm depressed," while suicides now are simply symptoms. Suicide= more Wellbutrin.
I still think they "mean" something, and I try to interpret it, but the focus nowadays is certainly not to interpret suicide as an expression of anything. Too bad.

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===== ====== ===== The Last Psychiatrist: What An Obama Presidency Means For Blacks
This is not an anti- or pro-Obama article, so get over yourself.

Not widely (anywhere?-- seriously, am I the only one?) discussed is the effect of an Obama Presidency on the relationship of blacks with other blacks. Because Obama has almost all black voters, there's the feeling that he's going to unite them, do right by them-- but how? Are all black people the same?

I'm not the only one to notice a widening divide among blacks. Before WWII almost all blacks were poor. Post WWII you get the beginnings, now widenings, of blacks moving in different classes, especially working class/middle class. No one noticed this (i.e. no one complained) because incomes across all classes rose comparably.

That stopped at the end of the 1960s; from then on, incomes in the lower classes went stagnant, while the others continued to rise. That might have been due to lower inflation rates, or the weakening of labor unions and the welfare system in general. Or, it might have had to do with the beginning of psychiatry as a supplemental welfare policy. Pick your own untestable explanation.

But the result is that one group of blacks is moving along the class ladder-- up and down-- like anyone else; while another (very large) group stays stuck in the bottom. The two groups are philosophically united on matters of equality, opportunity, etc-- and are both voting for Obama, but their needs are completely different.

These differences have not been as politically urgent because race has been more important than class.

Blacks, with good reason, have their hopes tied to Obama. But as blacks are not all in the same class, his policies will not affect them all the same. Same with McCain's policies-- the difference is blacks may be hyperaware of Obama not meeting their expectations.

So if Obama wins, we may have a new era of race relations in which the class, not race itself, plays the larger role.

A hierarchical relationship of lower classes receiving "protection" and "land" from upper classes in exchange for their "work" (read: servitude) is a rough definition of feudalism. This pretty much describes the country 1968-2008, especially as it applies to blacks and Hispanics. What makes feudalism work is that each class accepts their role.

Blacks have been so unified by race that they have not had opportunity or energy to try unifying by class. For example, workers could have tried to obtain more power/money/jobs/benefits by strengthening trade unions. Instead, much more emphasis was placed on the role of discrimination laws and affirmative action. It's impossible to judge whether this move was right or wrong. But that's the way it played out. Racial differences increased in importance, class differences decreased. It parallels the social dialectic: "equality" was replaced by "diversity."

That's likely to change. The class differences will be more apparent under Obama. It's tempting to assume all blacks will benefit under Obama, and that's probably accurate; but the point here is that some will benefit more than others. Along class lines. And the resentment is likely to be more acute because of the higher expectations.

Turn off your Caps Lock. I am not judging this, I'm guessing at the future: if Obama wins, then race is on the way out, and class is on the way in.

I am not at all saying whites will be more or less racist. I'm only describing what I think will happen to blacks.

That means: increasing power of labor unions; decreased emphasis on diversity laws/affirmative action.   Progressive taxes and consequent resentment all around. And the resultant dividing of the Democratic party to accommodate different classes of blacks who now need new representation. In short, the beginnings of class struggle within blacks.

There's a book about how class struggle replaces the race struggle, but I can't remember what it was called.

----

I should caveat all of this and say that there is one specific black person for whom race will still be the defining characteristic: Michelle Obama. Barak has managed to overcome this, but Michelle will be held to an unfortuante standard well articulated by Chris Rock, who said that the equality he wants is to be allowed to fail, and not have the failure be linked to his race. Michelle Obama will not have this luxury, and God forbid she misspells potato or chokes on a pretzel on a trip oversees, America will never forgive her or her race.

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===== ====== ===== The Last Psychiatrist: What Are We Voting For?

An article, over a year old, which must be posted again.

There isn't really an easier way to say this: that cavalier, simplistic attitude towards history; myopic beliefs which bypass logic or reason, supported only by intuition and faith; and a hatred of others who have a radically different perspective on humanity-- that's not Bush, that's us. I'm not even saying this perspective doesn't have some merit; but know thyself, yo.
Most of our enemies share a common social philosophy that, at its core, is psychic: don't trust any country where women are regularly more powerful than men; where individuals are more important than a collective; and where personal beliefs and freedoms trump historical identity. Because that means that its men are weak, its individuals are selfish, and they cannot be trusted to act in the long term interests of their own people. Rather than responding seriously to worldview, with equal fervor-- and it's so easy to do it-- the country has instead chosen to release this press statement: "Bush lied."

It is, to me, the most important article I have ever written on this blog.

https://thelastpsychiatrist.com/2007/05/the_wrong_lessons_of_iraq.html

Please, read it, and pass it around. It's happening now.

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===== ====== ===== The Last Psychiatrist: What Design Flaws Need Fixing In This Blog?

Font, spacing, line spacing, color, layout, etc-- if anyone has an eye for design, some help would be appreciated.

And please no "one huge design flaw is you're an idiot!" jokes. I'm already aware of those. That's what the rum is for.

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===== ====== ===== The Last Psychiatrist: What Did You (Not) Do In 2008?
To the twenty-somethings out there:

Twenty years from now, when you look back on this year:

you had ideas

And you had youth and energy

you had interest rates so low they were negative relative to inflation-- you could borrow money at literally no cost.

and a ready made excuse in case of failure-- Oh, I was young then

and little responsibility, no family

You had the internet-- global distribution or marketing, for free
    information on anything, for free

And then the time passes.

At least you got your file ready for the promotions committee. At least you got that summer job that'll look good on your college application. At least you watched the whole season of Grey's Anatomy and only vomited twice.

I'm sure, in twenty years, it will have been worth it.

Stop trying to figure out what you want to do with your life, and just do something with it.

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===== ====== ===== The Last Psychiatrist: What Does The Woman Who Feels No Fear Feel?

I'm going to need another drink

An article in Current Biology.

A 44 year old woman named SM has a rare, autosomal recessive disorder that resulted in bilateral amygdalar damage and...

On no occasion did SM exhibit fear, and she never endorsed feeling more than minimal levels of fear... SM repeatedly demonstrated an absence of overt fear manifestations and an overall impoverished experience of fear. Despite her lack of fear, SM is able to exhibit other basic emotions and experience the respective feelings. The findings support the conclusion that the human amygdala plays a pivotal role in triggering a state of fear and that the absence of such a state precludes the experience of fear itself.

If you know anything about science, you know it loves to yell at people. It also loves rules, some of which are arbitrary at best but good luck telling anyone, ordinary folk just say, "well, science said so" and the ones who should know better don't have time for your nonsense, they have to submit 50 page grant applications to a review committee comprised of a cabal of cronies or they won't make full professor.   /rant.

The rule for today is amygdala= fear. So no amygdala means no fear.

SM, who lacks amygdalas, was Fear Factored with snakes and spiders; they took her to a haunted house (though not a Japanese haunted house which doesn't so much scare you as destroy your soul forever); they made her watch clips from horror movies.

But she wasn't scared. She exhibited, and said she felt, no fear.

II.

Don't hit up a brain surgeon quite yet.

SM not only can't feel fear, but is impaired "in recognizing fear in facial expressions, and in aspects of social behavior thought to be mediated by emotions related to fear." Which seems consistent with the expected result of amygdalar damage.

But others noticed something interesting about patients with bilateral amygdalar damage, and by "patients" I mean the exact same patient as the one tested in the above article, "SM." They found that she was indeed terrible at detecting fear in faces-- but it was because she didn't look at the eyes. When she was told to look at the eyes, she had no trouble detecting fear.

("SM eyes" means SM was told to look at the eyes)

This is borne out by other studies which find that the amygdala is primarily involved in fear detection when you are looking at the person's eyes. Body positioning and gestures, fear displayed by the mouth-- the amygdala doesn't seem involved in processing fear from those cues.

So the incorrect interpretation is to say the amygdala is needed to perceive fear. A more correct interpretation is that the amygdala is involved in fixating and processing information about emotions coming from cues from specific contexts such as the faces' eyes. You can see why this interpretation doesn't make it to the internet.

II.

What's going wrong is that one way associations are made into two way relationships. It is true that the amygdala is routinely observed to be activated during conditioned fear responses, but that's not the same as saying that it is the amygdala that is necessary for experiencing fear.

On top of which the terms are ambiguous. What's fear? Another patient with the same disorder as SM had normal mood and affect, and I'll quickly point out that this man had no problem experiencing fear. But guess what happened at age 38: he developed panic attacks. Missing two amygdalas did not help him, but 75mg of Effexor did. Take that, anti-Pharma backlash.

Wired Magazine interviewed the Current Biology study's author:

"What that suggests to us is that perhaps the amygdala is acting at a very instinctual, unconscious level," says Feinstein.
Well, not exactly. Another group had got hold of SM and this time flashed images of faces too fast to be detectable by the conscious mind. Normal people are able to detect fearful faces more easily than, say, happy faces. SM, lacking amygdalas, shouldn't show any difference-- but, in fact, fearful faces broke into her consciousness much more quickly than happy faces, and just as quickly as for normals. So unconscious perception is intact despite the absence of amygdalas.

III.

Though I've pointed out some inconsistencies in the studies of the amygdala-- not to mention the studies of SM-- the real "discovery" of these papers is this: all three of the "groups" I cited share at least one author.

Unless we are positing these authors themselves suffer from some kind of brain lesion, we need a better explanation for the discrepancies.

It isn't that they are not aware of their own findings, but that we are not aware of them. Unless you're motivated to look up everything any time you read anything, then each paper comes to you in a bubble. If you take it and read it and learn it, you will almost always get it completely wrong. It's worse if you're getting your science from the popular press, which is basically like reading only the 97th word in The Waste Land and then writing a synopsis. "It's about canasta, I think."

Most real neuroscientists-- not psychiatrists or even neurologists- understand that the common paradigm of structure-phenotype is overly simplistic.

More generally, the brain doesn't so much process information as apply a set of built in solutions to every single piece of information. It constantly learns and reorganizes, recognizes patterns and rebuilds.

In the case of the amygdala, it is involved in fear (conditioning), but it is more generally involved in making decisions based on incomplete information. It helps reduce ambiguity through learning. How the impairment of that facility manifests in an individual may be very different: SM feels no fear, the other guy gets panic attacks. Some people gamble more; or take more risks; or don't learn from experience. Etc. It's not just what's damaged; it's what each individual compensates with.

In other words, cutting out people's amygdalas is a terrible idea.

Feinstein says the new findings suggest that methods designed to safely ===== ====== ===== The Last Psychiatrist: What Else Causes Suicide? You'll Never Guess

In which I take the semiotic logic of medication induced suicidality to its inevitable, silly end.

Using nothing more than a Volvo. And without lawyers.

With the recent news that anticonvulsants double the rate of suicide, I got to thinking: isn't Klonopin (clonazepam) an FDA approved anticonvulsant?

Sure, it has different pharmacology than the other 11 studied, but Lamictal, Lyrica, Depakote, etc are equally different. So if we're going to pretend that we never had to take pharmacology in med school, if we're talking class effect, then Klonopin gets the warning.

Which may mean that all benzos should get the warning, since, well...

But why stop there? Antidepressants carry the warning across pharmacology. SSRIs, TCAs-- even Seroquel has the warning ONLY because it's now an "antidepressant" for bipolar disorder. Again, the FDA would like us to pretend that doctors had every M, W, F 9am-10am off in med school. We're not postulating the pharmacology is the cause, since they are all different-- we're saying it's a class effect. Ok, well, what else is an antidepressant?

Well, a number of medicines not FDA approved. Lithium, even though that's supposed to reduce suicide. CBT or other therapies? They must ultimately act on some biological pathway, right?

...inevitably, there can only be one conclusion: psychiatry causes suicide. You are all on notice.

And so, reductio ad absurdum, let's all stop this nonsense.

Some have trouble with my seemingly out of hand dismissal of a link between medications and suicidality.

The problem, like everything else, is semantics.

If they had said meds cause dysphoria, or confusion, I'd buy on board.    The problem is the link to suicidality-- a complex behavior. If SSRIs cause suicide, then they should just as logically promote the sudden need to buy a Volvo. Yes, that specific. Not cause a feeling of emptiness you need to fill with a material object, or even the sudden need to purchase an object-- but rather the specific need to buy a Volvo. These warnings aren't saying the patients are miserable, they're thinking of running away from home, or cheating on their spouse-- they are thinking of killing themselves. Not other people, either-- themselves.

You might say that the med is simply one factor, it adds to other things-- like another log on a fire. Ok, fine. But that's not the same as causing suicide, it's not even the same as "increasing the rate" of suicide.    Being on an antipsychotic for schizophrenia may lead to more regular credit card payments since you're thinking more clearly, but no one would ever say Zyprexa doubles the rates of Visa payments, even if it were semantically accurate.

I have an additional philosophical problem with it all: these warnings don't just exaggerate a medication's side effects, they demote suicidality to little more than a side effect.

In essence, these black box warnings reduce the complexity of suicidality into less of a behavior or activity and more of a reaction, a reflex. You might think that's not the intention, and I'm sure you'd be right, but that is the result.   Note that no one is attributing any other complex behaviors to these meds as a side effect-- not increased marriage, or desire to learn French, etc.

Suicide thus becomes MORE of something that can happen to you and LESS of something you do because you feel a certain way. It's subtle, but it matters. It's a corruption of language to escape the-- well, nausea-- of massive freedom; it says behaviors occur, not get chosen.

Psychiatry rarely argues nature vs. nurture anymore, not because it's been solved but because it's become irrelevant-- either way, you were now made and will inevitably act accordingly.

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===== ====== ===== The Last Psychiatrist: What Goes Wrong In A Psychiatrist's Family?

So maybe I am generalizing a bit, but I'm trying to get at something that isn't easily explained by science: why do so many psychiatrist families go bad in the same way?
In my experience (see, there's my disclaimer) psychiatrist-parents go wrong in a very specific way. They judge behavior, not the person. It sounds like a good thing, I know. For kids, it's a disaster.
Psychiatrists identify the behavior, but then focus on changing not the behavior directly, but the underlying cause of the behavior-- which is still not something intrinsic to the person. If a guy with bipolar spends $10,000 in a week, psychiatrists link the behavior to the bipolar, and then try to medicate the bipolar. (NB: "the patient has bipolar," not "the patient is bipolar.")
The obvious problem here is that maybe the guy spent $10,000 in a week because he doesn't give a damn? Or he wanted to impress some girl? i.e. just because someone has bipolar, doesn't mean every breath he takes is related to bipolar. Psychiatrists are going to deny that they make it so simple, but in actuality they do: the moment you raise the dose of Depakote, you are sending the message that the behavior was related to bipolar.
The psychiatrists with children-patients handle their kids in the same way. They teach them what they are allowed to do and what they are not, what is acceptable and what is not-- but make no judgment on the kids themselves. Doing this denies the kid's identity, which is the whole purpose of childhood to begin with. Rules then exist in an invented framework, or worse, in a vacuum. There's no internalization of the rules; there's no superego. Just some arbitrary limits on id.
If you tell a kid that a behavior is unacceptable, the kid has learned nothing about himself; he's only learned that this one thing is something he can't do. But if you make the kid own it-- make the behavior part of his identity, then he has a chance to change his identity. Instead of learning it is unacceptable to take his brother's potato chips away, he can learn that he has a choice: to be the kind of person who takes chips, or the kind of person who doesn't.
I understand the trickiness of this; you don't want to make the kid feel like he is a bad person. But you do have to find a way to teach him that if he does that thing again and again, then he is a bad person. Is that what he wants? Who are you, kid? Who do you want to be? This also allows his to take personal credit for doing something good:
And you can see the creation of a future borderline here. For God's sake, will someone please tell me who I am? Give this storm of emotions some context? Right now, I get angry/sad/thrilled/terrified over nothing, it just comes over me-- I wish I could be angry/sad/thrilled/terrified over something. But all people ever do is tell me what I can and can't do. If I do something bad, people freak. If I do something good, no one even notices. No one likes me for me, they just over/underreact to what I do.
There's a second lurking trouble: parents' control of their affect.
The psychiatrist isn't supposed to get mad at his patient; but then he comes home, and tries very hard not to get mad at his kid-- just tells him the behavior is unacceptable, gives him a time out, whatever. But guess what? The psychiatrist is exhausted, eventually his patience runs out, and BAM! a tsunami of anger.
calm&firm...calm&firm...calm&firm...EXPLOSION.
The explosion part can come at any time, depending on how much patience the parent has that day. And that's exactly the problem. What does the kid learn? That this ethereal rulebook for what is acceptable and unacceptable only has two, binary results: no affect, or all affect-- and you never know what you're going to get.
In the biz, this is called inconsistent parenting.
What the kid needs to know are the rules of the game; they need the parent to be consistent, predictable, so that they can be safely chaotic, experimental, exploratory off of your foundation.   You want her to know exactly how you'll react if she tries pot, you want a superego so well constructed you're superfluous. And you want levels of emotion, different things get you more or less angry. We know you went berserk because your boss is a big jerk whose been riding you all day, but your two year old thinks you went berserk because she spilled the milk. Geez, sorry. May as well try heroin, what's the difference?

It doesn't necessarily mean you have to be an angry parent-- your predicted reaction could be anxious acceptance or loving disappointment-- but it has to be predictable. And it has to be about the kid, not the behavior. The kid needs to know you're connecting with them, not what they do, or else they'll think that the only way to connect is by behaviors.

You can see the further development of a borderline here: what the hell do I have to do to get some emotional response from you? Kill myself? Keep pushing until you finally blow up? I don't even feel like I'm alive, but I'm not sure that you are either-- or is it just me, that I matter so little that I can't even get a little affect? You're insanely jealous if I talk to another guy, but you totally ignore me when I'm with you. At least with jealousy you're being real with me. Etc.
Trust me on this: at age 2, a kid feels your rage and your love the same. It's exciting, and they haven't yet learned to fully differentiate the two feelings. What counts is the amount of emotion, not which emotion. (Horror movies and porn are the same to a 14 yo for this reason.) Fast forward 20 years-- that all-out screaming match with your boyfriend felt weirdly relaxing.
And so you have a scenario: busy psychiatrist, often tired, can't generate much emotion past anger-- and it can come at any time. No deep connection with the child as a person-- as their kid, yes; as the sum total of their behaviors, yes-- but not as a developing individual. The kid learns that as long as some things are done correctly-- e.g. school-- they can get away with other things that the parent won't notice, e.g. pot.
Oh, and this is the best part: if the kid (adult or child) becomes a psychiatric patient, they now have a bond with their parent-- and the parent's over-involvement in their kid's psychiatric care is the framework for a relationship. It's analogous to helping them build a go cart.
And that's all the kid ever wanted anyway.

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===== ====== ===== The Last Psychiatrist: What Happens If Pharmaceutical Marketing Disappears? Part 1

Everyone (including me) thinks Pharma is too heavily involved with the practice of medicine. So we try to think of ways to stop this. Restrict gifts and consultant fees to doctors; decrease, or at least separate, industry funding from research; and, of course, no more reps in doctors' offices.

These all sound like great ideas, how could you even come up with an argument against any of them?

Here goes.

As a bonus, I even offer a practical long term solution.

The core issue is that Pharma exposure represents a conflict of interest. Does anyone understand what that term actually means? Ok, let me ask you a question. What is the plural of "conflict of interest?"

a. conflicts of interest
b. conflict of interests
c. conflicts of interests

Not so easy to answer, because any of them could be correct. You can't create a workable policy against something so vague it can't be pluralized . You have to target the individual conflict and weigh it against the individual interest. It may be a conflict of interest to take money from Merck while doing AIDS research; it might also be a conflict not to.

Ask The Question Differently:

Instead of asking what should be done to curb COIs (clever, huh?) ask: what would happen if we succeeded?

1. No more reps.

I don't know what goes on in other branches of medicine, but if you get rid of reps-- and detailing, and "lunch and learns" and all that goes with them-- psychiatry will instantly grind to a halt, and people will die.

It is an indisputable point that reps know more about the medicines than the doctors do. Worse, doctors don't know much more than a patient on the Google. We can argue whether Lilly hid the diabetes risk of Zyprexa, but it took Pfizer's (launching Geodon) to tell us about it. Don't tell me that we would have learned about it from the extensive journal articles written in 2000 (three.) Doctors only recently discovered Vioxx had a cardiac risk, though Yahoo! News had an article about it in 1999. Abbott et al may have rammed Depakote down our throats through 2008, but it took Astra Zeneca to kill it.

2. No more Pharma education money.

A frequent complaint is that there's $1B of Pharma money in CME. Is that just extra money? What's going to happen if you take it away? Then there's no more education. All of post graduate medical education is done by Pharma. The residency didn't buy the textbooks for the residents, Pharma did. Pharma sponsors the short "throwaways" and supplements that at least get some readers, unlike the regular journals which get no readers. Pharma also pays for the CME.

Who's going to pay the CME lecturers? Who is going to pick the topics? The government?

Here's an anecdote: I'm talking to a psychiatrist, and finding it difficult to keep all the receptor pharmacology straight he says, "these new drugs are no better than the old ones, we should go back to them." Is that a fact, commtard? You want to go back to Trilafon and Pamelor? If perphenazine is so great now, how come it wasn't when they called it Trilafon?

If your reason for prescribing a generic is that it is a generic-- I don't mean sertraline vs. Zoloft, I mean imipramine vs. Zoloft-- you are worse than the guy who prescribes Abilify because Pharma paid him.

(More on separating Pharma from CME.)

3. No more Pharma research money.

Do you know how many clinical trials are done by Pharma? Lots. You know how many are done by NIH? Not lots. If there exists one person on the planet who can tell me what society got from the $68M tapayer dollars spent on CATIE, I'm listening.

Clinical research is performed for two reasons. Secondarily, it is to promote the science. Primarily, however, it is deficit spending. It gives jobs to people. Few clinical researchers end up studying their passion; they study what's being funded. If Depakote's paying, we're studying Depakote. You want a job at Harvard in 2004? Make sure you can spell Depakote. You want one in 2009? It's S-E-R-O-Q-U-E-L.

If Pharma stops paying, then there will be much less research, even if it is biased. People are missing the hidden benefit of the "biased" Pharma trials: they are still information. I know Depakote isn't a maintenance agent because of the failed trial that Depakote paid for. I know Zyprexa causes diabetes and weight gain because of Lilly's own data (and the data from comparator trials done by other Pharma companies.) I recognize Pharma spins the data, but you can't tell me the data is non-existent. (Though that is preposterously what was argued about Vioxx.)

If Pharma did not pay for these trials-- if we had to wait for the NIH to investigate Zyprexa's diabetes-- we'd wait a long time. And, per #1, without Pharma to inform us a study was even done, we simply wouldn't know.

4. No more Pharma building money.

You know that new wing of your university hospital? Who do you think paid for it? The New England Journal of Medicine? My favorite of all Pharma ironies is that a university will take $25M to build something that it will then ban reps from entering.

5. No handouts to doctors.

Why do doctors get entangled with Pharma at all? Is it really just greed? Then why not just move to California and prescribe marijuana out of a shack?

I'm going to write something that so extraordinarily impolitic that no doctor will even admit to hearing this argument, let alone agreeing with it:

Doctors don't view this as extra money, they view this as money they are entitled to.

$120k may seem like a lot of money, but no academic doctor thinks that university salary is what he deserves. So he does extra things for Pharma, or gets some unrestricted grants from Pharma to free up time (so that he can do "other" things). His assumption is he is worth, say, $200k, the University only pays $120k, and he's going to make the rest up.

BTW, that's why the University gets away with paying you $120k.

The same is true for non-academic docs. They didn't imagine they'd be getting paid so little to do not exactly the job they thought they had signed up for. So they make up the difference.

I'm not justifying it, I am explaining it. If you completely ban all Pharma money going into doctors' pockets, they will demand it from somewhere else. They are not going to be satisfied with $120k. Or 15 minute med checks at $30 a pop. And you'll have a brain drain-- many docs will actually go work for Pharma. I can't tell you how many times I've been offered jobs at Pharma-- easy jobs, at 2-3x what I make now. Good students will think twice about medicine. Maybe they try biotech. Or law.

Do not email me "what ever happened to working for the common good?" The only people who say that are not working for anyone, let alone the common good. Doctors do have a nobler sense of purpose, but not at half price. Sorry. It's America.

Before you take that money away, makes sure you have a plan B.

Solution:

In order to solve the problem, you have to adequately explain the problem. Right off: patients are not the customers of Pharma. Doctors are. Pharma isn't making medicines that people want/need, they are making medicines that doctors want/need, i.e. that they will prescribe. So the way Pharma operates is to either identify what doctors will use, and market it, or they wil find a way to take an existing chemical and market it so that doctors will use it. Viagra, a drug "for" pulmonary hypertension, was decided to be marketed as a penis pump.

Like everything else in life, the solution is the demand side.

(Part II here.)

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===== ====== ===== The Last Psychiatrist: What Happens To An Action Hero When We Grow Up?
Depends on what we want from him.

I. Gran Torino

Gran Torino is a film about Walt Kowalski. Walt is not a real person, of course. This is fiction, and by fiction I mean Lifetime Original Movie fiction, every possible cliche you could want in a film, and then some. Walt is an old, cranky, "these kids today with their rock music" Korean War vet. He's a tough guy, in a time when toughness is a liability. In other words-- to borrow a line from Dirty Harry-- he's a dinosaur. Two empty, weak, vapid grown sons; a neighborhood changed from men with families, who work hard for a living to immigrant gangs, "gooks and slopes" and American is going to hell, back when I was young we had to...

What Walt still does cling to, what's important to him, is a car. That's because he still believes in symbols of masculinity and all that nonsense. I know, God, what a fool. Just in case this point is too subtle for the crowd that once voted Titanic the best movie ever made, the producers plan to bash you over the skull with this point and name the movie after the car.   Get it? This old fossil still doesn't understand that cars don't have any real meaning, they're just stupid hunks of metal that only serve as proxies for an identity you wish you had-- not like an iPhone or a barbed wire tattoo or a vote for Change, things that really signal individuality.

I'm not spoiling anything for anybody by saying that Walt's character evolves, "grows," and whenever you see "character" and "grows" in the same sentence it almost always means it's either Oscar season or it's 3pm on a Tuesday and you're watching an Afterschool Special.

Walt does grow-- he "meets them halfway," "learns that they're not all that different," etc-- in other words, cliche, cliche that would kill this movie in every other circumstance, except one: Walt is played by Clint Eastwood.

It would be a gross over-simplification to say that Eastwood saves the movie. He is the movie. Walt isn't played by Clint Eastwood, Walt is Clint Eastwood. The reason the movie is watchable-- the reason such an otherwise trite and predictable movie doesn't go straight to video but instead gets a review in The New Yorker is because people want to see this transformation, this "growing" happen to Eastwood. Or, more specifically, to the characters that Eastwood represents. In short, the only reason this movie got a write up in The New Yorker is because it shows how Dirty Harry learned the error of his ways:

Walt's final acts in the neighborhood struggles come as a shock, but, in retrospect, they make perfect sense as Eastwood's personal renunciation of vengeance and also as a kind of down payment on an altered American future.
Slow down, Criss Angel, I know a mindfreak when I see one. Clint Eastwood doesn't have anything to do with this. It's not Clinton Eastwood Jr.'s personal renunciation anyone cares about, because nobody actually knows anything about Clinton Eastwood Jr. or his personal beliefs. It is all the characters that he played-- their renunciation people care about. People aren't seeing Eastwood play Walt; they are seeing The Man With No Name now aged 70 and living alone, still clinging to his horse, I mean gun, I mean car. That's the guy they want to see "grow," that's the guy they want to see admit he was wrong. Time Magazine's review doesn't have the header, "Clinton Eastwood Jr. Changes His Mind About The Use Of Weapons To Solve Problems." It says Cleansing Dirty Harry.

One might take pause here and ask two questions. First of all, why does Dirty Harry need any cleansing? You didn't complain when he was taking out serial killers or corrupt cops. And the answer is that the movie isn't a movie, or even a story, it's a mea culpa for a generation. Since there are no heroes anymore, then all those action movies, all that black and white, right and wrong, must have been very unsophisticated. Real life, real problems are considerably more... nuanced. Since there is no black and white, people do bad things not because they're bad but because they make bad choices.

Yeah, well, color me unconvinced, things may not be all black and white, but there is a black and there is a white and I know them when I see them.

And second: hey, stupid, what the hell are you talking about? Dirty Harry doesn't exist.

But we want him to exist. This generation, this, The Dumbest Generation Of Narcissists In The History Of The World, they hate heroes-- except dead ones, they're ok, and superheroes are ok too, people with magic or from other planets-- but human heroes are anathemas, they want to tear them down and show them to be regular mortals, flawed-- and the best is if they can catch them being hypocritical, nothing brings an impotent narcissist to orgasm faster, even faster than cheating wife stories, than detecting hypocrisy in the elites.

What they don't understand because they are stupefied by their jealous hate is that the real reason they want to show that heroes are flawed is because that would mean that heroes exist in the first place.

Gran Torino is a gift to the jaded narcisissist of today. It says, look, there aren't really any action heroes, violence really doesn't solve anything-- I see that now.

Ok, but what happens when violence finds you and a hero is needed?

That's why the end of Gran Torino fits so well-- this is a *spoiler*, though they don't so much foreshadow this ending as they do scream it at you from the opening scene-- he goes to confront the bad guys and dies in a hail of bullets-- the end which is so obvious and predictable but at the same time the only one that would speak to this generation of narcissists: when we need a hero, heroes are obligated to rise up and serve, but please have the decency to die afterwards so we can go back to second guessing the ethics of your actions.

We hate to be reminded that there are others who are better than us; but, for the love of God, please let there be people better than us.

II. JCVD

"I'm 47 years old," is Jean Claude Van Damme's third line in JCVD, the movie about the real JCVD, the actor, who fell through the rabbit hole into the world of JCVD, the character. The opening scene is him filming an action movie, and he gets... tired. "It's not so easy for me anymore." We get it.

JCVD is out of money, acute and chronic. He lost his child custody case. He's been passed over for a role. His ATM card is rejected, and his manager wants payment by noon. So he talks his way into a closed bank to pick up a wire transfer. Sorry, technical problems. Huh? "We're out of money." Huh?? The teller stares at him blankly, the guard uselessly. He finds it surreal-- until he deduces it must be a joke? Candid Camera? Nope.

It's surreal for the bank teller, too, of course: the guy yelling at her is none other than the famous action star Jean Claude Van-Damme. What are the chances? Actually, that's only half of the surreal: it's JCVD yelling at her, and she's also simultaneously being held hostage. The bank has been taken over by armed robbers.

The movie sets up the man JCVD against the image. The man doesn't know how to fight real bad guys. When the robbers beat up one old man, JCVD does nothing except hide behind a chair. A dozen times he doesn't punch one of the bad guys, doesn't try to grab the gun.   Do you know why? Because he's not a hero, he's a regular guy in real life.

Strangely/expectedly, when the public and the cops learn that JCVD is inside the bank during this hostage situation, what occurs to them isn't that he may help stop the criminals; it is that he must be one of them.   No one assumes JCVD is really JCVD the hero, but it is entirely plausible that JCVD is a criminal. Even his mother believes he is one of the bad guys. In fairness to her and to the public, they really only have two options: either a) he's a regular man who can be pushed into "making bad choices;" or b) this guy who had three wives and used cocaine can actually be a hero after all. Calendar check: 2008. Pick a).

In other words, it's easier to believe he's a criminal than a hero. It's easier to believe JCVD could be a bad person than a good person.

What happened? I think the generation raised on action movies felt betrayed. Those movies promised possibilities, promised that when you grow up, your powers will kick in. When you grow up, if bad guys take over a bank, you'll be able to use kung fu on them. It seemed not to have occurred to anyone to learn actual kung fu, or look up how banks are typically laid out, where the alarms are-- just in case. No, these skills would be uploaded straight by God when needed, sudden and immediate, just as they came to JCVD in Bloodsport. Life is a movie and movies are only 90 minutes long. Not a whole lot of time for training.

Well, the possibilities never came true, so heroes can all go to hell. And God, too, while we're at it, he didn't deliver either.

We got a brief moment of the possibility of 1980s style black and white American might with George Bush after 9/11, when half the country went, "hell yeah, let's go kick some ass!" and the other half went, "wait a second, don't you guys know we suck?" That being the full extent of our national dialogue. You see the results.

III. 1985: Tina Turner or Bonnie Tyler?

Both movies play with the concept of identity. Who are these guys, after all?

Walt, played by Eastwood pretending to be the aged Dirty Harry, is too old to engage in significant gunplay, and we all know that if it came down to it, he wouldn't be able to defeat a ten member gang, in real life. The actor himself is too old to pull off an action sequence. So what does he do? He allows them to shoot and kill him, thereby getting them all jailed. But it is entirely consistent with what Dirty Harry would do if he was old and alone. Identity intact, even if it is all made up.

JCVD has the exact opposite problem. There's a scene when one of the bad guys-- an aging, overweight, haggard man with a revolver, wants JCVD to demonstrate a "high kick the cigarette out of his mouth" tricks. He even puts his gun down on a chair in order to get out a cigarette.   You're practically screaming at the screen, take him out! But he doesn't. Again, this is intended to show you that JCVD isn't actually an action hero, he is actually a regular man, in real life. Except that he is also actually a championship kickboxer in real life. In that scene, a nine year old panda could have overtaken the guy. It's impossible that the director, or Jean Claude himself, did not think about this. The scene works because it shows even JCVD doubts who he is, doesn't know who he is. Here he is, actually something, and he's not sure about his identity.

You can't help but admire a man who knows his limitations-- ironically, a line from Dirty Harry-- but what we need now, in these days moving forward, is less awareness of our limitations, and more dedication to overcoming them. I'm not advocating people should be someone they are not. But it seems obvious to me that if you are going to be someone you are not, and are willing to put in the time, be a hero.

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===== ====== ===== The Last Psychiatrist: What Happens To Fake Studies?
What, you think they go back and fix them?

Here's the setup, from Scientific American:

Over the past 12 years, anesthesiologist Scott Reuben revolutionized the way physicians provide pain relief to patients undergoing orthopedic surgery for everything from torn ligaments to worn-out hips. Now, the profession is in shambles after an investigation revealed that at least 21 of Reuben's papers were pure fiction, and that the pain drugs he touted in them may have slowed postoperative healing.

A doc on various Pharma payrolls authors studies promoting Neurontin, Celebrex et al, and they turn out to be fakes. There are plenty of people who will/want to make the obvious points, so I'll restrict my comments to the less obvious.

I.

Reuben managed to trick some othopaedic surgeons to be coauthors on his paper. One such orthopod, Evan Ekman, was reviewing one of Reuben's studies.

Ekman agreed to review a Reuben manuscript on surgery on the anterior cruciate ligament (ACL) in the knee. But when [Ekman] asked the anesthesiologist [Reuben] for the name of the orthopedic surgeon on the study, Reuben ceased communication with him.
Undoubtedly, everyone is focusing on the identity of the unknown orthopaedic surgeon as a red flag. But here's a question that will become obvious once I ask it: how did Ekman know the identity of the author of the paper he was reviewing? This is "anonymous peer review," right?

Next: even if he was alerted by 9 pixies that it was Reuben who wrote the paper, why would he think he was further entitled to know the rest of the authors' identities?

I'm not saying he should/should not know; I'm saying that this had become so commonplace to him that he doesn't even think twice about asking; or telling Scientific American that he asked. He actually forgot to pretend peer review is anonymous.

You may also ask why Ekman was chosen as a peer reviewer in the first place, since Ekman had previously coauthored other papers with Reuben. Oh, yeah: when you submit a paper to a journal, you choose people you'd like to review it. This way there is no chance whatsoever of institutional bias.

II.

Then, last year, Ekman was invited by Pfizer to give a talk. While there, he was handed a version of the very manuscript Reuben had asked him to review, which had subsequently been published in Anesthesia & Analgesia. To his surprise, and horror, he was listed as a co-author: Reuben had forged his signature on the submission form, Ekman says.
If a tree falls in the forest, and no one hears it, does that mean everyone is deaf?

Ekman is an academic doctor who also speaks for Pfizer-- in other words, he's a "thought leader."    Does he not read the journals? Do none of his friends read the journals, to send him an email, "hey, saw your study..." If he's not reading them, is anyone else?

What is the impact of a fake study that no one reads? Think about it for a moment, here's my answer: volume. "There is some evidence that..." It doesn't matter if the study is wrong, or silly, or fake; just as long as it exists, to be able to get away with that sentence.

III.

You think I'm kidding.

The faked article that Ekman reviewed and then "coauthored," purported to discover that Celebrex helped reduce pain, and consequently promoted more vigorous participation in rehab.

It also found that patients used a lot less oxycodone:

Casual readers of this blog will perhaps be thinking, "hmm, 20mg less oxycodone, does that seem possible?" But astute readers of this blog will ask the larger question: where the hell did you find the graph? It's not still on PubMed, is it?

Oh, yes. It's also free direct from the journal.    Here's a follow-up study, also fake, also free.

"But surely the article is labeled as fake, or something?" Something being like a big red watermark that says, "RETRACTED"? No. The only hint is at the bottom, under "This article has been cited by other articles:" and one of the 12 citing articles is the retraction notice by the editor.

It's hard to explain why the article isn't simply deleted; or, better, loudly labeled as a fake so that we can learn even from fakes.

But it is very easy, very very easy, to explain what will happen to a large number of doctors who never read journals, let alone Scientific American, who may perhaps be motivated just to see how many articles on Celebrex there are in the world-- "wow, that's a lot"-- or read a review article that cites these articles-- reviews that will never find a forum for retraction or explanation.

It's even easier-- sit down for this one-- to explain what will happen to new research on Celebrex-- "does this thing work, or not?"-- now that Pfizer has absolutely no incentive to pay for it.

Good luck.

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===== ====== ===== The Last Psychiatrist: What Hath Google Wrought

The quote, "what hath God wrought" comes from Numbers 23:23, about the Israelites, but it was popularized by Samuel Morse when he sent it as the first message over the telegraph.
I've been telling everyone who will listen to buy Google-- it's up 140 points since I wrote about it a month ago-- because it is more than an investment, it is a paradigm shift.

Others have described the typical fears of a Google world-- boiled down, essentially, to "everything gets saved, and everything can be searched."
While true, there are nuances missing that are worth describing explicitly. Buckle up.
First, four basics:
1. Google is more than search; Adsense is much more than ads. Google records every search you make-- time, date, which links you chose, time between clicks, etc. It's a relatively simple matter to piece together a profile of the user, even without knowing the identity of the user, which Google knows anyway. But Google also has a general ability to know what websites you visit, independent of search. See those Google Adsense ads? They're javascript: every time the webpage loads, a request is sent to Google for the immediate creation of an ad, based on the contents of that page. If that page sends a request, then Google knows that you are there, at that moment; when you came, how long you stay, where you went next, etc. And yes, the information is recorded without you clicking on the ad. It is a technically easy process to follow an IP address across the internet, as it hits Adsense pages.
2. Google is the default backup of the internet. Read that again.
Every page Google's bots crawls is cached on their servers.   In other words, they have a copy of most pages on the internet. You may try to delete something from the internet, but once Google saw it, it's on their servers forever. There is also considerable redundancy: if you upload a pic to your site, it is in Google's cache, but also Google's cache of anyone else who used your pic.
Here's an example: there's a story about a woman upset because the Google van (which takes street level photos for use with their maps) caught a picture of her cat in the window.  She wanted the picture removed.  Removed?  From where?  She doesn't get it, she thinks Google has the photo paperclipped to the inside of a manila folder.  You can't remove it, it's not a possession,  you can't take it back-- it's like the spoken word and the spent arrow, it is past tense. It's not just at Google Maps; it is at BoingBoing, and at Google's cache of BoingBoing...
You know all those closed circuit cameras? Some of them are online. Look, here are some, live. Guess what? Now they're on Google, too.
3a. Google is an accidental monopoly...
People complained that Microsoft forced people to use their products by linking them with other products. For example, Internet Explorer was the browser because it came with Windows. Google, however, can't help being the end product of the internet. Consider email: you can choose to use Yahoo! Mail and not GMail because you are worried that Google keeps all Gmails. Fine; but if you email to someone with GMail, Google stores a copy and knows what you wrote, but now also knows your IP and email address; consequently, it knows other sites you've visited. Etc.
Imagine the post office copied every letter it handled, and could cross reference the contents of those letters with other databases: calendar; credit card/online purchases, physical location, etc.   Scary? Now imagine that the post office housed those databases.
3b. ...that cannot die.
Everyone worries about Google's growth, but who is worrying about its demise? Google has so much data that it actually takes up real estate all over the world. Let's say Google goes out of business. Who gets all those servers? All that data? Who gets a copy of the world, on the cheap? Whoever it is doesn't have to give us satellite photos anymore. What can you do with satellite photos that no one else has? Who gets to decide how to control all that data?

4. Don't Be Evil.
Well, okay, that's good advice, I guess, but what happens when the subpoenas come? Or the Russians invade? Or the Chinese commandeer/hack Google servers-- some of which are actually in China? Discussions about the legal aspects of privacy aside, if something exists, it can be found. Even if it's just a disgruntled organ donor at the Googleplex who decides to fork over terabytes of data to the highest bidder. An organization-- a security organization-- is only as strong as the weakest person. Go to the Googleplex and park your car. Do you see any potential weak links? I sure do.
As a quick example of how crippling this information can be: Google has recorded the surfing habits of every employee of Microsoft, including Bill Gates. And of two Presidents. And the Pope.
The Missing Piece
The above three are well known, if maybe a little paranoid. But what is so important, and never discussed, is this: Google will be around for another 100 years. At least.
So when I say that it knows everything, it knows everything across time. It doesn't just have insights into your character; it has insights into your character as you age, and the character of your family line.

Social Ramifications:
Used to be, "on the internet, no one knows you're a dog." Well, now everyone knows. But worse, there's no hierarchy of identity. You may think you're Chariman of Oncology who occasionally played World of Warcraft 7 years ago. But if a Google search reveals 10 hits about WoW, and only one of being a doctor, then guess what? You're a nut.
The narcissism I always refer to is characterized by a vital need to self-identify.  You want to pick an identity, and you want others to accept it even in the absence of facts or behavior.  "I read Hegel, I'm an intellectual."  No, you're a coffeehouse agitator.  I can tell by the undershirt.  What Google has done is to make this self-identification impossible.  Before, you could be exposed only if someone took the time and effort to background check you.  Soon-- hell, now-- it will require no effort.  When the brooding artist-type you met at Starbucks calls you up to deride romantic comedies, inauthentic japanese food, and Ambercrombie and Fitch, but your cell phone shows you a picture of his (read: parent's) house in Irvine, well, that pretty much ends that, doesn't it?
Apparently, incoming college freshmen already know their future classmates through Facebook. Worse: the parents know their kids' future classmates. Remember the clean start college gave you? Well, forget it.

Parenting:

The focus is on who is monitoring our children.  What are they up to?

Well, think about this: your kids are investigating you.

Remember that time when your mom was 19 and she was in that wet t-shirt contest?  No?  Well, your kids will get to remember yours in AVI format.  Oh, and that DUI conviction?  Remember that vapid comment you posted on the Daily Kos? (Hint: ten years from now a high school freshman will cringe at its inanity.)   And, lo, the IP address search.  How did your IP end up on pornotron.org?  (Yes, the non-profit.)

Did you realize that your future daughter in law will be checking you out? "Billy, did you know eight years ago your Dad...?" This didn't occur to you?  Then I guess it didn't occur to you that your son's reply will be, "Sigh. Yeah. I knew."

(As an aside, the very fact that you are surprised by the possibility that your kids are googling you is evidence of the cultural narcissism I'm always referring to.  You are the parent, your child is yours, you monitor and control it-- it doesn't occur to you that they can exert the same power over you.)

Parenting has always required a degree of acting.  You can't be an effective parent if there is not at least the illusion of moral superiority; children rely on an unchanging moral stance to be able to test limits and to establish a superego.  While it isn't a disaster that your kid knows you smoked pot in high school, it doesn't help.  But it is a far worse when your kid learns it without your contextualization.  Consider: "Son, I smoked pot, but..." vs. reading an email when you were 20 where you recommend it to a girl you're trying to bed...
Google compresses time. What you did might feel like it was a long time ago, but your kids "experience" that memory immediately. Additionally, they are raised in a world where the past never disappears, so they do not connect with your language of "a long time ago."   For this reason, identity will be fixed at an earlier age.
Look deeply into your childrens' faces.  You will never remember them as well, as accurately, as they remember you.
Medicine:
It's beyond me that no one else has mentioned this.
Google wants to set up a system for online medical records, so that they can be "transported"-- accessed by all the various medical providers in your life. This is not even great in theory.
First, does anyone remember the Seinfeld episode where Elaine gets labeled in the chart as a problem patient? And every time she tries to change doctors, the chart follows her, and she can't get anyone to work with her? Let me assure you that in psychiatry this already happens even without the chart. If you want to ensure a two tiered system of medicine, enact medical record portability.
Next, medical records will thus be searchable, like GMail. See all those Zoloft ads? Guess why. Think drug reps know too much about doctors prescribing habits? How about how they will know the demographic characteristics-- diagnoses x epidemiology x financial status x etc-- of the patients he treats?
But the worst is this: genomics. It's not too far away that doctors will be running genetic tests as often as they run CBCs. Where is that going to be recorded? Imagine that your DNA can be cross referenced with your surfing habits. And your kids' DNA with your surfing habits. Imagine the preposterous world where Google "Adsense" predicts what products your kids might be interested in based on your life cycle... (Update: 23andMe.)
Here's a scary, sad, non-porn example: "Mom, why am I getting so many ads for breast cancer prevention?"
Think how good a Google search is using only a few keywords. There is no reason why Google can't suggest to you state of the art, or at least evidence based, treatments, tailored as well as possible to the information in your medical records.   So much for doctors. At best they retain their importance as diagnosticians. (Oh, and how much more accurate if the Google medical records happen to link up to your numerous emails that begin, "oh my God, I was so wasted last night...")
Look, people, I'm not saying Google will do it; I'm saying that it is no additional effort at all to do it.

Memory

You know the hippocampus? You won't need it where we're going.

Memory takes practice.  I can remember the phone number of almost everyone I meet, because I practiced that skill.  Most people are the opposite, however, because they directly dial much less often.  Same with my calendar (in my head vs. PDA.) And if you don't remember someone's phone or address, you can always google him.
I don't know anyone who quotes whole passages from books anymore. Very few even know any poems. Pretty soon, we won't be so great at memorizing 10 digits at a time; or directions; or names. This isn't a bad or good thing, but it will be different. Factual memory will be less important than "feeling," "experience."   "That was an awesome party." Yeah, who was at it? "Hold on a second, I'll tell you exactly..."
Soon, you won't need to remember anything about "him." You want to call him? Say, "call that guy, red hair, worked at the gas station..." and he'll answer.
Here's a crazy idea: that guy walking towards you that you don't remember? His "device"-- cell phone/PDA/GPS/brain implant signals your device, and instantly not only do you now remember who he is, but you know a lot of other stuff about him you didn't know before. Solid.
General facts will no longer be rehearsed, learned, because they can be immediately accessed. I don't mean go-to-your-laptop-and-search immediately, I mean wristwatch, or earpiece, or contact lens immediately.
(A propos of testing: multiple choice has to vanish. All education now has to be essay.)

Not just that, but access will be faster.  Question: how important is it to prevent memory loss in dementia, when they can access the memory instantly?  So recall (e.g. Ach?) won't be important: processing skills (DA and Glut?) will be important. Maybe that's a good thing.
Mobile Search
I know, it's about target ads. Ok. What do you have when you have infinite storage capabilities, and voice recognition search software (e.g., Google 411)? You have a permanent database of everyone's voice. Across time, under different circumstances. Across generations. And always tagged with all your other information. So when Google hears your voice through someone else's phone while on vacation in France, or on a CCTV, or whatever-- it can helpfully say, "oh, that's Bill, he likes cooking and Asian porn, let me send him some targeted ads!"
It's Taking Over The World, You May As Well Profit From It
A lot of people think Google, at 620, is overvalued. They're not just wrong, they are casualties. It has a $200b market cap; it has $13b in cash, and no debt. It grosses $6b in profits a year, margins of 30%, and it's growing at 30% a year. It has time on its side.
I've long argued we are moving towards feudalism, away from national governments. Google is already gunning for the top spot.
Oh, I know, Google is just a big advertising company. That has satellite photos of the entire world that they artificially worsen because the U.S. Government doesn't think you should be allowed to have it.
What saves us, today, is that Google is a relatively small company run, really, by three people. But if it grows too big- if it becomes like an oil company, with tentacles into politics and world affairs and everything else-- in other words, if it becomes a lord-- you can just change the motto from "Don't Be Evil" to "Don't Be a Sucker." And then look out.

(long GOOG, obviously.)

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===== ====== ===== The Last Psychiatrist: What Healthcare Reform Means To Hospitals
You're all going to miss Big Pharma.

===== ====== ===== The Last Psychiatrist: What iPads Will Do To Your Family

awesome... masturbation just got a little easier

Chuck Hollis, a VP at EMC Corporation, writes about what buying the iPad did to his family. It's short, go ahead and read it.

And then I brought home the iPad.
...The members of my family immediately gravitated to the new shiny thing -- no prompting, no encouragement, no migration, etc. They are drawn to it like a moth to flame.
I now have this strange love/hate relationship with Apple. And I think it won't be long before I'm forced to make another trip back to the Apple store.

I'm not trying to ignite an iPad war, nor am I saying that the iPad is not an inventive piece of technology. The iPad has a market, but that market is plagued with a number of troubling appetites. But he'll never buy a desktop again? BS. Let's say you take video or a photo with a camera. There is currently no way to get that to an ipad except through a traditional computer.

The problem isn't the iPad itself, but what he plans to do with it. What he describes in this article is totally unproductive activity. Sending photos, facebook, and smiling, always smiling.

My wife asserted her rightful place in the hierarchy later that evening, and took it upstairs to the bedroom to relax while watching TV. Tap, tap, tap. Occasionally, she showed me something interesting she found online. And smiling.

Let me guess, she was watching HGTV and browsing GOOP.com, right? Consume, consume, consume.

He's describing a consumption device, not a production device. These aren't devices you use to create anything.   They are media consumption devices. Can you write anything of substance on an ipad? Do actual work on an ipad? I understand that it is certainly fun to use, and that it's neat. Does that justify $500 + $20/month?

And that's fine if that's what they are. They'll be successful for the same reason all kinds of things are successful. It makes people smile. Great. So do Vente Moccachinos, which I assume comes in red as well as standard black. People buy gourmet cookware to scramble eggs. They buy high performance cars to sit in traffic.   Just because I think it's stupid doesn't mean I don't also think it won't be hugely profitable, nor does it mean I don't understand the product. I understand it perfectly. These devices are for people who approach computers and the web the same way they approach TV.

Can I rip 1080p blu-ray discs to it? Can I edit HD video? Can I write a document on it longer than 100 words? Can I prepare a presentation, work on a spreadsheet, etc.? Will it run MAME? Will it do all these things at the same time?

And to his main point: "I don't think I'll be buying desktops anymore." Yes you will, because judging from the article you buy every stupid piece of crap that any of these tech companies ever make. "As I think about it now, we've got a fleet of 6 PC desktops of various vintages and three Windows laptops -- two of them that actually work well. On the Apple side, we've got an iMac and two MacBook Airs of different vintages. We just updated the family NAS server to the most recent Iomega device." So yeah, there are a few more desktops in your future.

The criticism here isn't about the tech. I just bought a MacBook with edges so sharp I can slit my wrists on it while I'm looking for the right click button. But it's a slick ride, and boots up fast enough for me not to punch the CPU. Is it "better" than a PC? Sure, I'll grant that.

My criticism is about the mindset. Not everyone-- settle down-- but many look at Apple from the "if I only had the right equipment, I could--" perspective. It's a false idol. None of these products will improve the quality of your production if you are not already producing. And there's a very good chance that it will suck the time and energy out of your life, exactly like porn.

Forget the All-Clads and the Whole Foods. Go buy some Acme non-organic eggs and mass produced waxy tomatoes, and figure it all out.

---

Stock tip: the fact that I finally bought an Apple can be taken as some sort of top.

----

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: What Is A Real Man?

"Real Men Don't Buy Girls" pretends to be a PSA against child sex slavery. What it really is an effort in rebranding.

In this clip, you see Ashton Kutcher. If you had to find 300M Americans to be on a list of "Real Men," and every person in America except for Ashton Kutcher had been eaten by a giant squid, Ashton Kutcher would still not make that list, ever. This isn't to say he's a bad person-- he stuck with Demi (admittedly, not hard to do) and seems to have done right by the Willis kids-- but he's not in Jung's Psychological Types.

In the clip he's disheveled, unshaven, he's wearing a knit cap, he has dirty socks-- real men don't care about their appearance. But he can't even fake it; his stubble is carefully maintained, and I don't know any guy in the world who has an extra pack of socks available "just in case." No guy buys socks unless they need them right now; if you see a guy picking up a pack, he stepped in a river. You see a guy buying underwear, he's going to put them on in the car.

Real Men, as defined in these ads, means 35+yo men acting like 10th graders. All of the men in the PSAs-- Justin Timberlake, Jaime Foxx, Bradley Cooper-- are unmarried. Kutcher is technically married, but in the PSA he "isn't." Yes, he's wearing a ring, but the room is obviously only for him. There are no decorations; the only visible book is "Travel As a Political Act" which they give you free at high school graduation. There's a crumpled shirt in the corner, waiting for Saturday when he can take it to his mom's.

===== ====== ===== The Last Psychiatrist: What is Off Label Usage?

Some guys in Georgia do a massive study and discover that doctors use medications off label. They also determine that that's bad.
The real question is not why we use them off label, but why we persist in thinking that means anything.

First, the core problem with the paper, and the entire thesis of the validity of indications, is that the definition is recursive. A drug has an indication because it was found effective for a cluster of symptoms that we have defined as a disorder. This does not necessarily make the disorder valid, and it does not preclude the drug’s efficacy elsewhere.
In other words, it tells you what it is good for, but not what it isn’t good for.

So what is the value of an indication?
Can someone clarify the basis for the arbitrary distinction between “dementia related psychosis” and any other kind of psychosis? Is there new PET data that I missed that distinguishes the two?
Similarly, to say a drug “is” an antidepressant doesn’t mean it isn’t actually an antipsychotic. For example, what is it, exactly, about Prozac that makes it not an antipsychotic? The only legitimate answer is that when tested, Prozac didn’t work in psychosis—not that an antidepressant can’t be an antipsychotic. It is an artificial hierarchy that puts “antidepressant” below/weaker than “antipsychotic.” Try the reverse: can an antipsychotic be an antidepressant? Why is that easier to believe?

Thus, categorizing a medication based on an arbitrary selection of invented indications to pursue—and then restricting its use elsewhere—may not only be bad practice, it may be outright immoral.

I do not make the accusation lightly. Consider the problem of antipsychotics for children. It is an indisputable fact that some kids respond to antipsychotics. They are not indicated in kids. But don’t think for a minute there will be any new antipsychotics indicated for kids. Who, exactly, will pursue the two double blind, placebo controlled studies necessary to get the indication? No drug company would ever assume the massive risk of such a study-- let alone two-- in kids.
And which parents will permit their child in an experimental protocol of a “toxic” antipsychotic? Rich parents? No way. The burden of testing will be undoubtedly born by the poor—and thus will come the social and racial implications of testing on poor minorities. Pharma is loathed by the public and doctors alike, and the market for the drugs in kids is (let’s face it) is effectively already penetrated.   There will not be any new pediatric indications for psych meds. Not in this climate. Think this hurts Pharma? It's the kids that suffer.

Lastly, the likely most common laments to this paper will be that it will be used by insurance companies to further restrict the practice of psychiatrists. Too bad. If psychiatrists cannot be bothered to learn how medications work and their appropriate usage, then unfortunately the State must intervene. It is, after all, their money, and it is not infinite. But restricting formularies based on "approved indications" (read: nothing) is not the solution. If the problem is economic (and it is) then you need an economic solution. And you're not going to like it.

-----------

Off-Label Use of Antidepressant, Anticonvulsant, and Antipsychotic Medications Among Georgia Medicaid Enrollees in 2001.” Hua Chen, Jaxk H. Reeves, Jack E. Fincham, William K. Kennedy, Jeffrey H. Dorfman, and Bradley C. Martin 67:6 2006.

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===== ====== ===== The Last Psychiatrist: What Is The Best and Healthiest Coffee To Drink?

A short digression on my fourth favorite subject.
Does coffee raise blood pressure? Does coffee elevate cholesterol? Does coffee hurt your liver? Does coffee taste delicious?
At the outset, you need to know that not all coffee preparations are the same. The diterpenes cafestol and kahweol are the alleged cuplrits in the negative effects of coffee, especially raising cholesterol and increasing risk of coronoary artery disease. However, these are lipid soluble and are almost entirely filtered out by paper filters. Mix coffee grounds and water in a pot, and boil. Pour off the cofffee into a glass. Drink. Now look at the glass. That oily residue is-- well, oily residue. You don't get that with a filter.

For example, here is the breakdown of lipids in coffee: filtered coffee: 7mg/cup. Boiled and unfiltered (Turkish): 60-160mg/cup. Metal screener (french press): 50mg/cup. The types of lipids in each were the same (no selectivity in lipid filtration.)   So how you make your coffee matters.
Blood pressure: as long as you're a regular drinker, don't worry.
Reports of coffee elevating blood pressure are misleading, because they aren't done they way we drink coffee: daily. Going from nothing to a triple espresso raises blood pressure; but chronic coffee drinking eventually allows for normalized blood pressure.
For example, the much repeated finding "unfiltered boiled coffee causes a significant elevation in blood pressure, especially in women" is misleading: the study actually found that if you switch exclusively to boiled unfltered coffee from filtered coffe, your systolic blood pressure rises about 4mm Hg. However, switching from filtered coffee to abstinence did not have any effect on blood pressure or heart rate. Another study found a trivial change in blood pressure (-3.4mm Hg) after two months of abstinence (afgter 5 cups/d.)
Interestingly, a metaanalysis of 16 studies found that chronic caffeine (400mg/d) raised systolic blood pressure by 4 mm Hg. while 5 cups coffee/d (>500mg caffeine ) only raised it 1.2mm Hg.) This was corroborated by another study finding >5 cups lead to 1.35mm Hg increase.

Cholesterol: raised slightly by unfiltered coffee, and possibly with filtered.
Initial reports had found that drinking unfiltered coffee was associated with higher triglycerides and cholesterol levels than filtered coffee, because the filter removed almost all (80%) of the causative substance. Another study found unfiltered caused higher cholesterol (but not TG) than filtered; filtered coffee had no effect on lipids over no coffee at all.
These findings were slightly contradicted in a recent study: Abstaining after 4 cups/d reduced cholesterol by about 12mg/dl. Drinking filtered coffee raised cholesterol by about 11 mg/dL. For perspective, 4 cups/d of whole milk would raise cholesterol by about 14mg/dL.
The question t ask here would be, how good was the paper filter?
Coronary/heart disease: no.
Retrospective analyses find that >4 cups/d, but not <2/d, had almost double the risk of coronary disease; however, prospective studies found no increased risk.
A review identified possible explanations for an increased risk of heart disease in coffee drinkers including a genetic predisposition to slower caffeine metabolism in some people, and the presence of diterpenes (which raise cholesterol) in unfiltered coffee . However, the same review found several studies indicating a protective effect of moderate coffee drinking, which they conclude is related to the antioxidants.
One study found heart attacks more frequent in coffee drinking women than abstainers: but was only usefully relevant at <7 cups/d, which doubled the heart attack risk.   However, a gigantic 85000 middle aged women prospective 10 year study found no effect of 6 or more cups coffee/d on coronary heart disease.
For what it's worth, unfiltered coffee seems to be associated with higher rates of heart attacks than filtered.
But it pays to wait: a week after I initially posted this, an 8 year prospective study in the elderly found a dose dependent (i.e. greatest >4 servings) protective effect of caffeine in cardivascular mortality (reduced by 50%) (but, oddly, no effect on cerebrovascular mortality). Importantly, these were normotensive individuals.

Suicide: Opposite of smoking: drink up.
Gigantic 10 year prospective study of 86626 female middle aged nurses: suicide rate was reduced by 60-70% in those who drank more than 3 coffees/d, all other factors controlled.
A Finnish study of 43000 people over 14 years-- 216 suicides-- found that 2-5 cups/d moderately (30%) reduces suicide risk, while >8cups increases risk 1.5 times. (For reference: "heavy drinking" (weirdly: 2 drinks/d) or smoking had about the same risk.)
A 1993 study looking at death from any cause found a reduction in suicide risk (RR 0.87 per cup) with increasing coffee.
Liver cancer and cirrhosis: can't hurt, may help, especially if you're an alcoholic.
The same 1993 study above also found a lower risk of cirrhosis (RR 0.77/cup). The same authors, in a more recent study, again find such a reduction in risk, and find lower levels of liver enzymes ALT and AST. An Italian study found coffee reduced the risk of hepatocellular carcinoma from any cause (Hep B, C, alcohol, etc); same in the Japanese, and in the Japanese in a prosepctive trial. And in Americans chronic liver disease rates were half in 2 cups/d drinkers.
Recent evidence suggests that this may be partly due to caffeine, but also to phenolic acid antioxidants which are not present in tea. The authors cite reports of such ingredients' protective effect sagainst various forms of liver damage (including Tylenol.)
So if you're going to drink coffee, there are two prudent things to do. 1) drink filtered coffee, made with a good filter. 2) drink medium roast, not dark roast. The roasting process burns off volatile chemicals such as caffeine and the antioxidants.
For this reason, my vote for best, healthiest, and most delicious coffee to drink is Dunkin' Donuts.

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===== ====== ===== The Last Psychiatrist: What Percentage of Suicides Had Depression?

In the same JCP issue in which atrocities were committed, McGirr and friends looked at 351 Canadian consecutive suicides, and then performed a psychological autopsy to find out what had been wrong with them.
Almost all of the women killed themselves with two methods: overdose (46%); surprisingly, hanging (38%). For men, it was hanging (53%) or firearm a distant second (16%). I don't know what's going on in Montreal, but it's different than LA. (Less guns? More trees?)
In comparison to men, women were more likely to be college grads and have jobs, to have a lifetime history of depression or anxiety, but less likely to have ever abused alcohol (26% females vs 44% males).
In the six months prior to the suicide,
Depression: males 52%; females 56%
Anxiety: males 10%; females 15%
Alcohol: males 31%; females 18%.

So there it is, more than half of suicides were depressed at the time of the hanging/shooting/OD.
Which is fine, but there is one statistic the authors neglected to report:
Number of patients who had been in psychiatric treatment at the time of death: 10.
The number 10 doesn't appear in the study, and repeated attempts to get the actual number from the authors were failures: "we don't have systematic data." Ok: the same group put out another study: out of 422 suicides, 28% had been to psychiatry in the past year. Let me translate: 70% had not.
If a tree falls in the forest, and no one hears it fall, shouldn't we get some guys out to the forest?
---

Addendum: in the Oct 2006 Am J Pub Health, the authors find that suicide rates have been decreasing-- dramatically-- especially for the elderly since 1985 (from 21/100k to 16/100k) and youth since 1995 (14/100k to 10/100k). But it's worth repeating that the number of actual suicides is still very small.

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===== ====== ===== The Last Psychiatrist: Does CNBC Cause Market Volatility?

Books will be written about this financial crisis, but no one has brought up one important factor, and it is summarized by this single soundbite, from Friday September 17, 2008, at exactly 4:00pm EST:

"...and there's the closing bell, I'm Bob Pisani, and I just have to say in my 18 years at CNBC, I have never been more proud of my news team than I am now...."

They are good reporters, dedicated and hardworking, I'll give him that, but was the reporting itself better than it was on other days? What else would there be to be proud of?

The problem, as everyone on CNBC reminds, is one of liquidity, not solvency. In other words, the financial institutions have money, but are overleveraged. As long as no one calls in their loans, as long as there isn't a run on the banks-- as long as these institutions are given time, then they can rise the capital, or deleverage. They just need time.

Bear Stearns didn't have time. FNM, FRE-- no time. Maybe in a year housing prices rebound? No one can wait that long. Etc, etc.

And so one must wonder what part CNBC and the media in general played in this very real catastrophe. Maybe if the media hadn't been reporting about-- sensationalizing?-- financial Armageddon so zealously, perhaps there wouldn't have been a run on money market funds, calls to congressmen about the safety of their pensions, etc-- and maybe the institutions could have had-- what, another month? Two weeks, even? AIG held out until the end, defiant, until the government kicked them in the head to roll over. What could they have done in another two weeks?

Who knows?

It's hard to say what relationship there is between, say, CNBC's ratings and measures of market volatility:

Oh wait, never mind, it isn't that hard after all.

In case you can't see it, here's the same graph with the CNBC ratings data shifted two days:

The greatest monetary shift in this country's history is real. But, as with politics, science, law, medicine and the arts, we don't interpret reality, we interpret other people's interpretations of reality.

Which is why I say: America hates the red pill.

(Data above from http://tvbythenumbers.com)
===== ====== ===== The Last Psychiatrist: What Should Count As A Disease?
Quick, look over there!

Ronald Pies writes:

What exactly is a "mental disorder"? For that matter, what criteria should determine whether any condition is a "disease" or a "disorder"?

and attempts an answer. It is this:

I know you can't read the words in this graphic, but what's important is that his answer isn't an answer at all, it's another hierarchical model, not a physics-style concrete truth. Nothing the "Wovon Man" guy would sign off on.

This is not a failing of Pies; there's no possible way he could be expected to come up with a concrete solution. But his answer is just as ambiguous, relative, and subject to individual prejudices as simply defining a disease as "anything in which the person or surrounding people feel suffering. Severity of illness correlates to amount of suffering."

I'm not saying my definition is better-- it's equally valid, or invalid, or whatever you want to believe this whole project is.

It should be fairly obvious that "disease" is an entirely subjective term that can be applied legitimately to anything.   "The disease of right wing conservative ideology." See? 50% of you agreed. Not jokingly agreed, mind you-- but found a serious element of truth to that diagnosis.

Point is: people can't be trusted to value anything. Remember that idiotic book Nudge? Look where it got us.

II.

You may want to ask whether "what constitutes a disease?" is something you really want the answer to. If it turns out that alcoholism is not a disease, then what? Close all the rehabs?

Trying to determine what is, or what is not, a disease is a distraction, a red herring. The real question is, what are we going to do about that thing?

The Average Joe is at a bit of a disadvantage. He feels something's amiss with say, "ADHD is a disease" but doesn't have the language to articulate it. So he says, "ADHD isn't a disease because it's too vague, not based on any physical pathology." He says that, because he's trying to argue like he thinks a doctor might argue, using the word "pathology" or using definitions. Consequently, his perfectly legitimate suspicion is dismissed, because his arguments seem weak to a doctor.

He needs to be true to himself. He doesn't need to argue it on doctors' terms, doctors need to argue it on his terms, because it's a social problem, not a scientific one.

His real problem with the diagnosis is what he's actually best suited to speak about: the social ramifications. "If you call ADHD a diagnosis, does that mean he gets extra time on the test and I don't?" That's the part that matters. Whether ADHD is "real" or not, whether there is a gigantic gaping pus hole in a "patient's" brain where something important should be is not what matters to Joe. What matters is, "he got this far even with the pus hole, why should he get a leg up just because he can't do as well as I can?"

Pies tries to argue like a doctor, because he thinks this is going to be decided by doctors. He doesn't realize that it has already been decided, by forces larger than him and Joe.

As if to reinforce that point, here is the advertisement found between Pies's article:

There's a social problem masquerading as a medical problem. Oh, you think it's a Pharma ploy to make money? Nope. Society wanted Pharma to take this problem off their hands. If you're wtaching it, it's for you.

So what if it's true? Do we believe that treating ADHD will lower the divorce rate? Should having ADHD mean you get to keep the boat?

No one would dispute that the symptoms of ADHD exist, or even that they cluster together, or that they respond to Dexedrine. It's probably likely this is related to some physical change. But? What does having this mean? Does it mean society is obligated to pay for it? Defer to it? Those are the questions that matter, not whether it is a "disease."

The word "disease" is a safe house, it's "base." It's a clever accounting trick. Since "diseases" are defined to be value neutral and require both money and deference, rather than argue whether ADHD is worth our money and time, instead argue whether it is a disease. Once it gets labeled as a disease, no further arguments are necessary-- it's a disease. Don't be a heartless jerk. Step aside.

That drives Joe bananas. And it should.
===== ====== ===== The Last Psychiatrist: "What should I say/do to my son after this happened to him?"

count

From Ask Reddit:

I'm a single parent living with my 15 year old son. On Sunday a classmate of his died. (I will not say how or where as the last thing I want to do is bring the parents more grief by me posting it all over the internet.) I didn't know the girl personally but she was in most of my sons classes to my knowledge. He was very shaken when he heard the news, which is to be presumed but he has not talken to me since the incedent, he has stayed in his room since sunday night, I leave his dinners at the door.

Today while looking at the girls facebook, which is crowded with messages, I saw a post made by my son.
I have never told this to anyone but I have had a massive crush on you since the seventh grade. This was the year I was going to ask you out. I hate myself because I didn't ask you sooner and I miss you so much. Goodbye.
I had no idea he felt this way about her as he has never told me. I am starting to think he is depressed. I keep trying to talk to him but he wont reply. Should I get a psychiatrist for him. I honestly have no idea on how to deal with this. Please help.

Edit

Im sorry to say that he did the same thing as before, he closed the door before I could speak. Thank you for all the coments but I am really stuck now.

I know people are saying that I am prying into his life too much, but I need to know if he is going to her burial.

Just for clarity, I am his father

Edit Again

Hes going to the funeral. I heard his door close and there was a note at the door. "I am going to the funeral, if you are at work, I will bike there. I will not miss it."

Edit Its about 3 am here, I walked into his room about an hour ago. I just wanted to see him agian to be honest. He was on his bed sleeping. The room was covered in tisues. His eyes were bright red from rubbing them.

I was going up to tuck him in when he siad "What is it dad" I was taken back that he was awake and even hearing him was a shock. I told him that I will drive him to the funeral if he wants and that he should get some sleep. He asked about work, I siad that doesnt matter. I kissed him goodnight then left.

I think we had a breakthrough.

II.

These are the four "Best" comments:

Time. Too much interference an attention during a normal grieving process can be damaging (see studies on the negative effects of debriefing therapies post-trauma). Be there, but let him be. I would only start to worry if his grades drop, and he continues to isolate himself (I'm talking months later). He will probably benefit greatly from attending the funeral and connecting with peers there.
PhD student in clinical psych

--

I think sending him to a psychiatrist would make him feel like there is something wrong with him. Losing someone special always takes time. Whenever you see him give him a good hug. Tell him he can always come talk to you whenever he needs to, but never force him to talk. He'll come to you when he's ready, if he ever is.

--

I had a lot of friends die when I was growing up. Between junior high and the end of high school, the count was closing in on two dozen. I'm not a psychologist or a counselor, but I went through a fair amount of grief, so take this for what you will.
Everyone deals with grief differently, so it's hard to say how much time your son needs or how this will affect him long-term. He needs to talk with someone--talking will be like letting poison from a wound--but he has to decide when and to whom on his own terms. The key is to make sure he has opportunities.
I didn't have a great family growing up, nor did I have many friends. I was the outcast loner because we moved to the school after cliques had formed and I didn't go to church, so I didn't have an instant social connection with anybody. School counselors are usually worthless, and several of the people who died were the ones I would talk with about serious matters. It was my chemistry teacher, late after school one day when I stayed to make up a test, who decided to forget the test and just spend time talking with me. We talked for over an hour and a half and then she drove me home, and that conversation did a lot to get me through. Prior to that, I had spent 4+ months locked in my room, staring at a wall in the mental equivalent of shock, just totally shut down. She was open to talking, and that was enough.
So be open to your son. Don't ever try to force him to talk, and don't force him to go to counseling if he doesn't want. Just provide space and time, and maybe even awkward silences, to give him room to talk.
If he's crying, let him cry for as long as he needs. Don't tell him it's OK or that it'll be alright. Don't say a damned thing. Just let him cry. Crying's like talking--it lets that poison out and can clean the soul a bit.
PM me if you want to Skype or something, as I'd be happy to talk more. After going through so much of this stuff when I was younger, I really want to do what I can to help others going through the same stuff. Let me know if I can be of any help.

--

Just let the kid grieve. Everyone needs time to let out all their emotions when someone the loved dies.
--
I lost a friend at about that age and I can tell you that 15 year old boys are primarily going to rely on their peers to help them come to terms with this. Seeing that OP's son is a 15 year old in 2011, much of that interaction is going to take place online and via cell phone.
The best thing OP can do is let him know your there to talk if he wants to (he won't, but it's still good to hear) and make sure he's got enough minutes/texts on his phone.

--
And the "Best" comment (1061 votes):

It's only been two days since the girl died and he's clearly grieving. Just give him some time to come to terms with it and let him know you're there when he's ready to talk about it.

III.

Here's the problem with that otherwise well intentioned advice: it isn't for the Dad, it is about themselves.

The majority seem to think that the son is grieving a dead girl he had a crush on as if he had a relationship with her, but all of this grief is over a girl he did NOT have a relationship with. I suppose it is possible that he was desperately in love with her from afar, and that her death has devastated him because he felt she was The One. But it's far more likely she represented something to him that her death has either obliterated or made very real.

Note the manner of death isn't mentioned. Hmmm. Let's assume, oh, I don't know, it was a suicide. How would that change our reading of the son's "grief" and his emotional connection to her?

Furthermore, no one thought it relevant that this is a son being raised by his father ONLY. I know we live in a post modern, nothing-is-remarkable period, but I'd like to suggest that that is odd, 3% of kids odd; and that therefore his relationship to women, to certain types of women, and to the loss of women, is probably of central but clearly unexplored importance.

And: he posted publicly on facebook. It's not surprising he posted his grief on facebook, it's surprising that he posted that he had a crush on her from afar on facebook. He's 15, right? The age where you are too embarrassed to announce unrequited love? Which means he's not telling her he likes her, he's telling everyone else a message that is encoded, "I was in love with THIS girl."

"Just let him grieve", "just give him time" is not good advice, because you do not know the context of this grief and most of what I am seeing tells me this is not normal grief. I could be wrong..   Do you want to wait to find out?

So, Dad, if you are reading this:

    If your wife died, you need to reach out to your son. If it can't be you, or it doesn't work, you need to find someone else to work through, even if it is a school friend. Even if it is the parent of a school friend. You cannot leave him to his own.

    If your wife is alive (e.g. divorced) get her involved. Maybe there's a good reason not to get her involved, but if there isn't a good reason not to, bring her in. Any aunts? grandmothers? Sisters? Female friends of his?

If he's drinking, it's not good.

You're his father, not his friend. This may make a certain kind of conversation impossible, fine, but you still have to represent a kind of man, a kind of strength and presence and selflessness, "even if you do not want me I am here, permanently, no surprises" and you reinforce that by constant, honest, non-contrived connections. You don't approach him as a peer because you hope it will make a connection, you come at him as Dad. He can reject it, but he needs you to be a Dad to reject. You don't/maybe can't make him feel better, but you have to offer a foundation for his sadness-- "any lower than this and I'm here." (Tucking him in and driving him to the funeral was great.)

And, Jesus, no more food at the door, are you Japanese?

IV.

But there's one more piece of information that makes this all more urgent.

Consider you are a 15 year old boy, grieving a potentiality that you loved, wondering where that leaves you now. You have no place to express this loss, so you put it on facebook.

Now consider you are the father of such a boy, and you also have nowhere to turn, so you turn-- to reddit. It may be normal for a boy to go to facebook, or a father to go to reddit, but it is anything but coincidental that a father who is so out of ideas that he is even able to have the thought to turn to reddit is raising a boy who who is similarly out of connections and defaults to the pseudo-anonymity of facebook.

This is not a judgment against them, but you have to understand the context and the only context we have are the words. The father never mentions any other human being except his son and the girl. He does not mention talking to family, or teachers, or other kids. The father is not depressed and yet still operates in a tiny universe of two people. The father himself is Alone, isolated, struggling for a connection to someone and losing his only real connection to another person. So how do you expect a depressed 15 year old to act?

Both of their universes used to have at least two extra people: the father used to have a wife, the son used to have a mother, and now the son used to have a potential love. By my count, the father lost 33% of the population of the universe, and the son lost 50%. No wonder he's depressed.

Given this-- and, again, not a judgment, just a statement of fact-- given that they both operate in universes with very few people in it, the father must force a connection to his son. He cannot wait it out, he cannot give him his space, he cannot let him grieve alone in his room for a month and let him come out of it on his own.

If forcing that drives his son in typical teenage fashion away from him into the arms of other kids, good-- at least there are other people in his universe. But if that kid sadly drifts away from his father, into isolation, he will have lost 100% of the population of his universe. It will then be too late.

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===== ====== ===== The Last Psychiatrist: What Should Really Be Done For Autistic Children?

if only he had been diagnosed earlier

Though not my field, my recent experience (N=1) lead me to ask myself, and now you, a terrible question.

There are numerous modalitlies and medications and theories that are used to help autistic children. You try to find a treatment program that suits the child and the family, and you begin; then ordinary life intrudes: missed appointments, effective medications aren't well tolerated; unforeseen consequences, etc.

So I wondered: given unlimited resources, unlimited access, the best "clinicians" available in the world-- what could be done? I don't just mean rich parents; I mean someone like the president of the United States, with enough clout to be able to command the attention of anybody he wanted. What's the best possible outcome? It seems like we should know what that is before we move to a general approach.

For ease of discussion, let's just take the simple(r) case of a high functioning Asperger's boy. Bill, age 6, has social delay, speech and language delay, motor coordination problems but most major milestones hit appropriately, and no intellectual deficits. Struggles with empathy, with articulating emotions, acts out when frustrated. Fails the Eyes Test.

Is there a theoretical maximum to improvement? I can predict remission, "cure," in depression. Is it possible to take Bill and make him into an adult who would not be detected as ASD on objective testing? (Let's leave aside whether other people can tell there's "something about him.")

If the answer is yes-- that using the best of the best of all of the world's resources a child can eventually "lose the diagnosis"-- then the terrible question I asked is, does the treatment itself cause even worse damage?

Here are some of the structural problems of the treatment:

0. The diagnosis will make the parents want to try and help the child. This is axiomatic. No parent with access to services will be told their kid has a diagnosis of "PDD" or Asperger's and say, "not interested, let's wait a few years and see how this goes." Once a diagnosis is made, the psychiatric juggernaut is activated.

1. The race against puberty. That's how long you have to teach meaningful coping strategies before the gigantic burden of sexuality and adolescence hits you in the face. So let's agree that the majority of the work has to be done in childhood; parents won't wait.

2. Do you tell the school? Remember, these parents do not need the school to access services, they can get them on their own. Should they tell the school anyway? We talk about stigma, but the more dangerous and pernicious force is the contextualization of all behavior. Even if we predict "remission" by age 18, the existent diagnosis of ASD alters how they see him. If the kid fights another kid at recess, it could just be a fight, but it will be impossible for the school to see it as anything other than a manifestation of autism. The y may not treat it differently this time, but the kid is always going to be operating from a defensive position.

3. The treatment harms self-esteem. Sending a 6 year old to psychiatry and etc is fine, but as the kid gets older and understands the social interpretation of psychiatry, it is likely to be a blow to his self-esteem. (True?) And as the kids get older, they may make fun, or just treat him differently. Does treating autism lead to marginalization, poor self image, and... depression?

4. The treatment is necessarily ab-normalizing. The best treatment probably includes different things, e.g. play therapy, social skills group, horseback riding-- again, I am positing access to the "dream" treatment plan. All of those things take up time. When does the kid get to watch Secret Of The Kells and play Legos instead of "you only have time for one, we have to get to Dr. Miller's by 4"? At some inflection point the treatments are taking time, energy and interest away from ordinary activities. Does he lose by not having them?

5. Other parents. Posit again that this treatment works, it makes the kid completely "normal" by age 16-- as defined as undetectable on objective testing. He has, however, been long identified as in intensive treatment. When the kid is 16, what parents are going to allow their daughter to go out with "the autistic kid?" I wonder if parents would much sooner let their daughters out with the "odd" kid (who never got treatment) then the perfectly normal kid with a diagnosis.

Etc. Certainly at the low end of functioning services become more valuable, but at some higher end of the spectrum... does intervention cause (un)forseen consequences?

Neither is this a question about "too much of a good thing." The question is: is the mere activation of the psychiatric infrastructure more harmful than helpful? If Bill Gates had been diagnosed... then what?

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===== ====== ===== The Last Psychiatrist: The Fundamental Error Of Parenting: What's The Difference Between a Tiger Mom and A Wolf Dad?

apparently, the secret to success is single parents

From NPR:

Tiger Mom Amy Chua... became an overnight sensation in the U.S. this year when she wrote about her tough parenting style. But she looks like a pussy cat next to her
mainland Chinese equivalent, "Wolf Dad" Xiao Baiyou.

"Wolf Dad" wrote a book called Beat Them Into Peking University.

Xiao, 47, describes himself as the emperor of his family. As such, he's laid down an extraordinary system of rules for his children.

"I have more than a thousand rules: specific detailed rules about how to hold your chopsticks and your bowl, how to pick up food, how to hold a cup, how to sleep, how to cover yourself with a quilt," Xiao says. "If you don't follow the rules, then I must beat you."

The last parenting book I read was The Road. I'm not sure that counts. I only got a quarter through it, but its principle advice appears to be to take all of your instincts and the collected wisdom of every movie ever made and do the exact opposite. This is terrible advice.

For my money: this Xiao Baiyou is a nut. But whether this guy is a nut or not is not as important to you as what the media constructicons want you to think he is.

I.

What you noticed first about this story is that he beats his kids and they go to Peking University. You did this because you assumed the story was a news story and were looking for information, and not a media construction showing you a facade. What does the journalist want to be true?

Instead, what you should have noticed first, right off the bat, is that the story explicitly juxtaposes this man with Amy Chua. That's the fulcrum of the story, it tells you what your frame of reference is supposed to be. The point is NOT that he beat his kids into Peking University, the point is for you to compare him to Amy Chua and no one else.

Amy Chua was called a terrible mom for being hard on her kids, but if she had been a dad the state would have sent in the police and Battle Hymn Of The Tiger Dad would not exist. It doesn't exist, which is my point. She was able to publish because her audience-- e.g. the readers of the WSJ where she first and exclusively published an excerpt of her book-- like to hear the words "college" and "success" and "how", but to soften it from mean parenting to tough parenting you have to make it all come from a woman, especially a non-American one. Rule #1 of stupid people trying to make sense of the world: the culture you know nothing about has all the answers.

Then to reinforce Amy Chua's methods as the gold standard for all the other demos who previously hated her, an alternative standard that goes too far must be created to appall everyone into agreement. One year after Chua went platinum, here it is. "Well bless my heart, beatings?! I know I don't like that method of Chinese parenting! And Amy's daughters are all so poised and pretty, not like those porphyria drones he has solving Hamiltonians in the basement."

Note the four key differences in the story:

1. He's physically abusive, so the audience understands him to be hatable.
2. Not American, but Chinese, in China. China = uncivilized. Hatable.
3. His story appears on NPR, Slate, mommy blogs, not on the WSJ. This is not an audience weighing the merits of a yardstick to the knuckles, they prefer passive techniques like evolutionary psychology and chemical coercion. Man acting like a man, father like a father? Hatable.
4. Amy Chua is a Harvard law professor, while Xiao Baiyou is a real estate mogul. Hatable.

With this information, the reader is now invited to choose which of the two images represents an American success story:

a.

b.

II.

Question: what kind of a person reads parenting books? I'm not being critical, I'm asking. Do the readers feel they are failing and need some advice? Or are they just looking to hate someone and are willing to pay $23.95 for the ammunition? I can see that someone might see the book and say, "hmm, I'd like my child to get into Peking University, let's see what he has to say," but that thinking betrays a cognitive error that both makes these books useless to you and is the reason you need such books: you don't think there's anything wrong with your parenting, you think you just need some helpful tricks.

Hence the popular parenting books/blogs aren't for special populations like Raising The Autistic Child or My Kid Saw A Gorgon, What Now? These are ordinary kids being raised by parents who are worried about what shows are appropriate for kids, but not about the commercials. "What? He's 7. It's not like he's actually going to go buy an Acura." You've failed.

"Good" parenting, apparently, is trying techniques on your kid that were never used on you, even though you still turned out just fine. "I think TV is bad, I won't let my kids watch it." Outstanding. But how do you explain how you watched 5 hours of TV a day for thirteen years straight and still turned out ok? Think it over for a moment. You'll never admit the answer: because you're different. You succeeded despite the TV.

But look around: everyone you know over 30 also did fine despite the TV, no lawyer ever says, "Your Honor, my client saw every episode of Bosom Buddies and McHale's Navy, I move for dismissal." Which is why I am telling you: TV is bad for the kid, but that thinking is much worse.

So too: sugary cereals, bullying, Playboys. None of those things are good for kids, I am not saying to expose your kids to them. But thinking that they will be worse for your kids than they were for you is the fundamental, narcissistic error of parenting. "My kids are weaker than me." Then humanity is doomed.

I know many white doctors who have their kids in Mandarin classes. Did that help them become doctors? "I want them to be able to compete." With whom? Mandarins? Seriously, what world do you envision in which Mandarin is the deciding talent, except working in Mandaria? Which is great if that's what they want to do, great if the kid is interested, but otherwise is this really how you're plotting excellence? "It also teaches you to think logically." So does actual logic. "It looks good on a college application." Everyone hates you.

Part 2 here.

My Amy Chua post

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: What's Wrong With Research In Psychiatry?

Apart from the high fives, bravado, and binge alcoholism.

Dynastic:

There are no independent psychiatric researchers. Young academics are mentored by older academics; this isn't optional, for either person. In virtually no circumstance do they study something entirely of their own choosing, it is either an outgrowth of the mentors' research, or is the mentors' research.

Distant from reality:

Young academics almost never work outside of the university. Theirs is all selection bias. The only patients they see are the ones the university gives them: either Medicaid/indigent on the inpatient unit, or patients of the disposition to want to be involved in clinical trials. Academics are like government economists: "we haven't had two consecutive quarters of declining GDP, so we're not in a recession." Regular psychiatrists are the management at Wal Mart: "I'm not sure what this is called, but no one is buying anything."

Groupthink:

Academic psychiatrists are nearly all on the same page, and refer to one another as if they have a relationship, even when they've never met. ("Chuck Nemeroff is doing some good work on...") It's pointless to list the other characteristics of groupthink here, except to highlight one: the purpose of groupthink is not to promote an ideology, but self-preservation, and this is unconscious. They don't realize that their lives are devoted to preserving the group, yet young researchers are brought on who connect with the group; peer reviewers-- and journal editors-- come from the group; grant reviewers, and NIMH people themselves came from, and support the group.

An example of groupthink preservation is the referencing of studies. Academics support their propositions with previous studies; however, no one checks the accuracy of these studies. No one has the time, and the group necessarily must trust the work of others in the group. Even if an error were to be found, it would be described as an isolated error. A cursory stroll through this site alone suggests just how "isolated" such errors really are.

Financially isolated:

Medicine is a market. Buyers and sellers.

Academics make a salary, but their survival at university depends on the grants they can bring in. That means their market, their customers, are funding agencies, not patients. It doesn't mean they don't care about patients, it means that the service they provide is nuanced and directed towards Pharma or the NIH.

If the funding agencies are stacked with people who like antiepileptics for bipolar; if the grant goes to Pfizer who is looking to create a bipolar indication, etc, etc, that's the research that can be expected. I'm not even worried that the results will be... predestined. I'm worried that such pressures direct what kind of research, what kind of questions get asked, at all.

Too much data

We're busy talking about bias and hidden results and skewed statistics and nonsense. So we call for more studies, as if they will somehow be better studies, despite no other structural changes being made. The reality is that we have information inflation: new studies have less value because they get lost; and old studies completely disappear, as if somehow their validity is temporal.

There are a quadrillion studies already conducted in psychiatry. There is plenty of data that can be analyzed, meta-analyzed, pooled, parsed. If all current research ground to an immediate halt, and researchers just looked back at what we already have, we would save billions of dollars in future research and future bad treatments, and we would learn so much.

Outcomes Research Is Purposefully Avoided, or Ignored:

You might think in a field with nothing but outcome studies (e.g. Prozac vs. placebo) I might not be able to make this claim, but I do.

Most studies are short term. The few long term studies that exist (e.g. Depakote for maintenance) are either equivocal (e.g. Depakote for maintenance) or show no efficacy (e.g. Depakote for maintenance.) And they are ignored.

But these outcomes are distractions. The question isn't is Depakote good for maintenance bipolar. The question is, is there any value to the diagnosis of bipolar? In other words, if you called it anxiety, or personality disorder, or anything else, and then treated them ad lib, would the outcome be different? Is there value to the DSM? You might argue the diagnosis leads us to the treatment, but in most cases, meds are used across all diagnoses, and more often than not a diagnosis is created to justify the medication.

Are hospitals valuable? You would think that by now we'd have a clear answer to this, the most expensive of maneuvers. I can say, however, that reducing the length of stay from several months to 5-7 days has not affected the suicide rate. I'm not saying they are or are not valuable, I am saying that I don't know-- and that's the problem. It is 2008 and there are more studies on restless leg syndrome then there are on hospital vs. placebo. You know why? See above.

Are one hour sessions associated with better outcomes than 2 minute med checks? I know 2 minute med checks sound bad, what I want to know is if they are actually bad. Higher suicide rates? More days absent from work? More divorce? More sadness?

The system is completely ad hoc, with each party yelling loudly to protect their fiefdom. It allows everyone to declare themselves an expert without having to prove it. Tell a Depakote academic you're suspicious about the utility of the drug, and he won't tell you you're wrong, he will tell you you don't understand. Try it. He will evade the existing data ("not enough people," "studies are difficult to conduct," "we know from clinical experience," "more work is needed") and rely on appeal to authority. Appeal to authority is the signal you're being bullshitted.

Outcomes research will never be conducted in psychiatry because its existence depends on not knowing the answers. It will eventually be conducted on psychiatry. You can't tell you're an idiot, someone has to tell you.

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===== ====== ===== The Last Psychiatrist: What's Wrong With The Hunger Games Is What No One Noticed

guess what happens next

When a media universally misses the point, it's on purpose.

I.

Rue is a little girl in The Hunger Games, and in the movie she's played by a black girl. According to Jezebel, Racist Hunger Games Fans Are Disappointed.

Well, six people are, anyway.

There's an underlying rage, coming out as overt prejudice and plain old racism. Sternberg is called a "black bitch," a "nigger" and one person writes that though he pictured Rue with "darker skin," he "didn't really take it all the way to black." It's as if that is the worst possible thing a person could be.

So there are some racist fans, so what? In itself, why would this be surprising? There are racists everywhere. I once asked a black guy where I could find some racists and he punched me in the mouth, turns out I'm a racist. Who knew? Actually, I did, because every time I see a black guy do anything odd I say to myself for no reason at all, "oh, hell no, oh no you didn't." This is going on in my head, silently, no audience. Apparently not only do I see race, I hear it. And god forbid it's a black woman, my neck and skull actually start moving from side to side as I think, "mmmm hhhmmmmm!"   Why do I do this? I don't talk like that. So much for individuality, so much for free thought, I am so polluted by the world that my reflex thoughts are someone else's. You don't even want to know whose thoughts I think when I see boobs.

Of course, if this racism was attached to a Transformers movie you can be sure that Jezebel would pronounce all of the Transformers audience racist. But in this case, it's only some of the audience who are racist, because progressive Jezebel likes The Hunger Games, and they're not racist. How can they be? They're post-feminists, i.e. the racism for Jezebel is merely an opportunity to criticize the bridge trolls who live in Central Time, just in time for the elections.

Most of the "racist" comments I've seen about this complain about the race from a anti-Hollywood, anti-left perspective, i.e. "there goes liberal Hollywood, pushing the liberal agenda."    The complaint appears to be not that they don't like black characters in general, but that this was some underhanded move to use the story to promote a political agenda, like making Sherlock Holmes a gay action hero. Now that's just wrong.

If that's the case I don't completely fault them, the story is important to these girls/women, and they feel betrayed that someone alters it to suit their interests rather than give a faithful telling of the story, which, as happens to stories, become partly owned by the audience.

The point here is not whether Rue should be black or not. What's interesting is how Jezebel seized on the racial controversy, but completely avoided the one bludgeoning them in the face for two hours: this is a book for females, written by a female, with femalist themes, gigantically popular among females, yet is more sexist than a rap video.

II.

Everything that's terrible about THG is in this sentence:

Hunger Games was written by a woman and stars a woman (much as we love JK Rowling, her series isn't named after Hermione) -- making it a true lady-centric blockbuster franchise.

Here's your first point of irony: this true lady-centric blockbuster franchise isn't named after Katniss, it's named after what happens to Katniss, which is why it is truly a lady-centric franchise.

How would you classify this book/movie's genre? Is it an action movie with a female twist? Is it a love story? A drama? Sci-fi?

No. It is a fairy tale.

III.

We can start with the obvious. The book is about 24 kids thrown into an arena to fight to the death, only the toughest, the most resourceful, the strongest will survive, and it better be you because your whole village depends on it. It is such a scary premise that there was some concern it was too violent for kids to watch. Well, big surprise: Katniss wins.

Hmmm, here is a surprise: Katniss never kills anyone. That's weird, what does she do to win? Take as much time as you want on this, it's an open book test. The answer is nothing.

This is not a criticism about the entertainment value of the story, but about its popularity and the pretense that it has a strong female character. I like the story of Cinderella, but I doubt that anyone would consider Cinderella a strong female character, yet Katniss and Cinderella are identical.

The traditional progressive complaint about fairy tales like Cinderella is that they supposedly teach girls to want to be princesses and want to live happily ever after. But is that so bad? The real problem with fairy tales is that the protagonist never actually does anything to become a princess. Forget about gerrymandering or slaying a dragon or poisoning her rivals: does she even get a pretty dress, go to the ball and seduce the prince? Those may be anti-feminist actions, but at least they are actions. No. She is given two dresses, carried to the ball, and the Prince comes and finds her. Twice. Her only direct and volitional action is to leave the ball at midnight, and even that isn't so much a choice as because of a threat. (1) The clear problem with this isn't that girls will want to hold out for a Prince, but that it might foster the illusion their value is so innately high that even without pretty clothes or a sense of agency a Prince will come find them. Sleeping Beauty and Snow White are worse: they don't even have to bother to stay alive to get their Prince.

The Hunger Games has this same feminist problem. Other than the initial volunteering to replace her younger sister, Katniss never makes any decisions of her own, never acts with consequence-- but her life is constructed to appear that she makes important decisions. She has free will, of course, like any five year old with terrible parents, but at every turn is prevented from acting on the world. She is protected by men-- enemies and allies alike; directed by others, blessed with lucky accidents and when things get impossible there are packages from the sky. In philosophical terms, she is continuously robbed of agency. She is deus ex machinaed all the way to the end. (2)

For example, though this is a story about kids killing kids, somehow Katniss never actually plans and executes any kids, she's never guilty of murder one. She does kill Rue's murderer, but it was reflexive, a defensive act. Importantly, she does not choose NOT to kill, she does not choose a pacifist position, she explicitly states twice in the book how much she wants to kill. But she never does it. She tries to kill big bad Cato at the end, twice, and fails. Only after he is torn to shreds by mutants does she perform a mercy killing on him, at his request. In other words, she doesn't choose to kill or not kill-- it doesn't come up. (3)

The story goes out of its way to prevent her from having to make choices and especially from bearing their consequences. Events unfold in such a way that it appears she made a choice, but decisions are actually made for her. At the end she and Peeta, her kinda-boyfriend, are the last two contestants left. Only one can live. What should happen next? Does she kill him? Or let him kill her? Think about it, what does she choose? Remember, this is about a strong female character forced to play a killing game. Wait-- never mind, they change the rules at the end: everyone's a winner!

"But she chooses to commit suicide at the end!" That would have been a choice, but the book robs her of that as well, this is the point. The book does not allow her to make irreversible choices, it lets her believe she is making free choices and then negates them, again, just like a five year old girl with terrible parents.

She does commit one consciously deliberate act, and it's quite revealing. At the end of the book, she's ambivalent about whether she loves contestant Peeta. But the Games allowed two winners only because they appeared to be in love; so all she has to do, for the cameras, is pretend to be in love with a boy she already likes a lot. But after all she's been through in the arena, this-- what is coincidentally called ACTING-- is what is described, in the shocking last sentence of the chapter, as "the most dangerous part of The Hunger Games."

This is not hyperbole. This is literally correct: for someone who has not ever done it, acting with agency would indeed be dangerous. But those stories aren't fairy tales, those stories are legends.

III.

That the book is successful or exciting is not the point here. What's fascinating/horrifying is that this fairy tale has managed to convince everyone, especially people who consider themselves feminists, that it represents a form of female empowerment when it is exactly the opposite. What you should not underestimate is how deliberate this magic trick is. This is society successfully pretending to change so that nothing changes. The goal is making the other team contribute to their own oblivion. The goal is status quo.

The classic feminist example of "robbed of agency" is the woman who "chooses" to wear makeup, do her hair, display/hide the right amount of cleavage. Is she choosing this, or is society imposing this false choice on her? Because if she feels she has to do it in order to land the account, then it's not really her choice. Hence a controversy about agency.

What makes this such an impossible, lose-lose situation for a woman is that this choice isn't about "what to do" but about who she is, what society wants a woman to be: while she must make herself look pretty, if she is observed doing this she is immediately and simultaneously critiqued for being vain. The decision about whether to be or not to doll herself up is thus somewhat up to her, but the judgment about whether she is vain is entirely out of her hands-- it is a judgment imposed on her for doing exactly what is expected of her. Her only hope is that she is can make herself look pretty enough that it looks like it was not on purpose, i.e reveal the results but hide the process. (4) This manipulation of her is all deliberate design-- what society actually wants is that it gets her to be pretty, demarcates her as an object to be gazed upon-- but not bear any of the guilt/responsibility for forcing her into this. If it works and you are pretty I guess that's some consolation, but imagine if you're not pretty but still have to go through all this, suspecting but never admitting that everyone is going to think, "why'd she even bother?"   Being pretty is in many ways worse, because you're not only competing with other pretty women but with yourself ("you look tired today") and, as the old saying goes, a beautiful woman dies two deaths. But before you go try some of our Nivea skin care products. That's the system, it wants you to participate in your own marginalization so you don't dare unplug. It's exhausting being a chick. I mean girl-- woman. Jesus. (5)

Though this is an example of the feminist agency problem, you should note carefully that the "society" that forces this false choice on women is actually other women, not men, and it starts with the overly invested way mothers reproach their daughters to "dress like a lady."   Certainly the original energy for this madness comes from men, from "the patriarchy", but if every man was executed tonight nothing would change tomorrow. It's on autopilot. Case in point: this story of a girl robbed of agency was written by a woman.

So this is why we have a book about a post-apocalyptic killing game that spends zero pages describing how Katniss kills anyone but spends countless pages on how she is dressed, how everyone is dressed. What will she wear? What kind of jewelry? Hair up? Will the "sponsors" like her better this way or that? Her chief weapon isn't a bow, it's her appearance.

This is also a good place to observe that the real life, pre-and post movie release controversies about The Hunger Games have also been about physical appearances-- not just race, but is Jennifer Lawrence too tall? Hair too blonde?

That's why The Hunger Games is such a diabolical head fake. Forget about it being entertaining, which I concede it is. It has managed to convince everyone that a passive character whose main strength is that she thinks a lot of thoughts and feels a lot of feelings, but who ultimately lets every decision be made by someone else-- that is a female hero, a winner. You wouldn't allow yourself to like a story where the woman lacks agency, so it's clothed in a vampire story or a female Running Man so it sounds like she's making things happen. Or, if you prefer, in order to allow you to like an anti-feminist story, it is necessary to brand it as a vampire story or a female Running Man. Regardless of how you phrase it, the purpose is to get you to like this kind of a story. It wants you to think this is the next step in female protagonists. But it's a trick: nothing has changed since the royal ball.

That these "adolescent girl" stories-- Twilight and THG-- have women who are essentially lead by men, circumstance, and fate-- whose main executive decision is "do I love this guy or that guy"-- is a window on our culture worth discussing. When you have a daughter, your first question should be, "how is the system going to try to crush her?" and plan accordingly. This story's answer is, "no matter what happens, just talk a lot and it'll sort itself out." That Jezebel is distracted by the racial angle here strikes me as an unconsciously deliberate avoidance of the larger issue. Oh, the audience is racist, that's the problem.

---

http://twitter.com/thelastpsych

-----------------

I.   The threat is not that her coach will become a pumpkin. It is "the longer you stay, the more likely you will be detected to be a fraud." This is a critical childhood anxiety (which is why it is in a fairy tale), a narcissistic anxiety, and a feminist anxiety. The only thing she has to offer are her looks, and those are artificial (makeup and clothes) and transient. Eventually, the botox wears off. Tellingly, it cannot occur to Cinderella to even anti-feministly use her boobs to seduce the Prince and then win him over with her charm/grace/personality. Ultimate decision and action is always someone else's (godmother, Prince, etc.)

2. To reinforce this point, consider that "deus ex machina" is translated, "god from the machine" where machine= people who made the story. So not an act of god, but rather the author putting a god into the story to affect things; the important implication is that it is not random but deliberate. So when Katniss's potential victim happens to be wearing body armor, it is not an accident that Katniss couldn't kill him, or dumb luck, it was the deliberate intention of the author not allow Katniss to kill him.

The purpose of deus ex machina in ancient stories was to place the final reconciliation at the spiritual level: God saved you, time to commune. But since Nietzsche said there is no god, "deus ex machina"= man, for the purpose of delivering earthly prizes. This is the essence of the fairy tale-- as magical as they may be, the end result is always an earthly reward (marriage, riches, survival) and never a spiritual one. Hence, fairy tales are vital to the religious and non-religious children alike because they act as a bridge away from spiritual to earthly ("time to grow up")-- the child's imaginary world directed away from more imagination and towards the practical; or, in other terms, away from the Imaginary towards the Symbolic.

3. So if Katniss tries to kill someone, and fails, she has agency; but if I, the reader, can predict that at no point will she actually kill anyone because I can tell the author doesn't want to put her into such a position-- and then she tries to kill someone and "fails", then Katniss lacks agency. Note that the person who is aware that he has free will feels as though he lacks agency ("it doesn't matter what I do") becomes either depressed or paranoid, or both.

4. An interesting exception is hair coloring. The brunette who dyes her hair blonde isn't trying to look Swedish, the point is to make sure everyone knows it's artificial because it's a signal: I don't want blonde hair, I want to be a <<blonde>>.

5. An example of this and Lacan's partial object is the 40 something woman who looks in the mirror and decides that her entire sexuality is in a single special part of her, say, her butt-- so she diets to make the butt look good at the expense of bony shoulders and a gaunt face. Men sometimes do the same to their spouses, empowering a single body part of hers with all of the sexuality, e.g. looking at the calf or the hip bone doesn't simply remind him of the 20 year old version of his wife, but becomes the fetish that replaces the long gone 20 year old version. But this isn't illusion or delusion, he is not imagining what his wife looked like, the single body part is enough to generate arousal, in the same way that any fetish (specific kind of shoe, or a foot, or a piece of lace) is entirely sufficient. The problem is that this doesn't make the woman look hotter, it replaces the woman, so now neither the 20 year old version nor the 40 year old version are necessary.

The extreme of this logic is in anorexia, where the whole body is sacrificed in order to get "thin"- but because the thinness isn't directed in a body part but in an idea, a feeling, they still wear baggy clothes not to hide their fat but to hide the collateral damage of emaciation to their body which they are completely aware of. They know other people think they're too thin, they know "87 lbs" is a small number, but the anorexic is trying to control an idea. "I can see that my shoulders are sticking out, I know everyone can see my ribs, but yet I know I am horrifically fat." The control, the act of not eating, is the special body part; it is the obsessed-over fetish that exists for its own sake.

Addendum: if you don't know how to read, you should probably click this.

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===== ====== ===== The Last Psychiatrist: What The Hell Kind Of Suicide Assessment Is This?

Do you know how many psychiatry journals there are? A lot. I get 8 peer reviewed journals mailed to my house, not to mention the shopping bag/week of "Insights" and "Reviews" and "Expert Series." What the hell could be in all these journals, other than drug ads? Is the field evolving that rapidly? I mean, just how much info can there be about Lamictal?
But I'm happy to announce that the hundreds of articles are all top notch, cutting edge stuff. Let's look at a recent one, about how to conduct and document a suicide assessment.
I'm a busy man, with a lot to read-- what are the main, state-of-the-art points that I need to know about suicide?

Awesome.
Also suggested was listening to patients, preferred over caning patients, which can sometimes be misconstrued as insensitive.

How can I tell who's at risk? Blood tests, cortisol levels, what?

Crap. Wrong again. All this time I've been looking for breast implants. Turns out, other signs include: frequent renting of Girl, Interrupted; being Anne Sexton; going through puberty in Ohio; mapquesting the longest way to the hospital; listening to rock music.
Keep in mind: these are the key points the editors and peer reviewers felt important enough to put in little sideboxes. Aces. Let's go on.
What questions can be asked to help detect suicidality?

Wow. Do the answers actually matter?
Later the article discusses medico-legal risk. That's what every psychiatrist wants to know: how to document a suicide assessment. What should you write so that if, God forbid, the patient does kill himself, then it shows that you asked the right questions and did the best you could?    What advice is there for reducing medico-legal risk? A sample write-up, perhaps?

Great, finally-- this is exactly the kind of patient we want to know about-- complicated, but not currently suicidal. Ok, what should I write in the assessment? To reduce medico-legal risk? I'm have a Moleskin, I'm taking notes:

Does anyone in psychiatric journals ever get discharged? Or are we in France?   The guy denies suicidality, and you're considering ECT? This is like writing a pamphlet called, "Practical Tips For Driving In Snow" with only two sentences: "It's so much safer not to! Have a Fanta!" (For a more practical, albeit not as well written, article on documenting the discharge of a suicidal patient, click there.)

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===== ====== ===== The Last Psychiatrist: What To Do About Sexy High School Girls Having A Slumber Party

wait, that's not sexy

A case, the summary of which is everywhere:

During another sleepover, T.V. took a picture of M.K. and another girl pretending to kiss each other. At a final slumber party, more pictures were taken with M.K. wearing lingerie and the other girls in pajamas. One of these pictures shows M.K. standing talking on the phone while another girl holds one of her legs up in the air, with T.V. holding a toy trident as if protruding from her crotch and pointing between M.K.'s legs. In another, T.V. is shown bent over with M.K. poking the trident between her buttocks. A third picture shows T.V. positioned behind another kneeling girl as if engaging in anal sex. In another picture, M.K. poses with money stuck into her lingerie - stripper-style.
And up to facebook went the pictures; and the school got involved; and the court got involved; and now I got involved.

Important to the story, these high school girls were volleyball players. Not important to the story, but featured in every one anyway, is that they were cheerleaders. We get it. They're white.

The judge ruled that the pictures were protected under the First Amendment, which is fine, but then said this, which is weird:

I wish the case involved more important and worthwhile speech on the part of the students, but then of course a school's well-intentioned but unconstitutional punishment of that speech would be all the more regrettable.

Why wish that? If it was more important and worthwhile, we wouldn't really have a controversy. The importance of the law is in these cases that don't have worth or importance.

II.

The set up is one of free speech, but there's a different game in play.

The judge explained that it isn't true that just any old photo/speech is protected, but speech that is "intended to convey a particular message" "understood by those" who would view it. In this case: this is funny (message) to the people on my facebook page who would understand that it was funny.

The fact that adult school officials may not appreciate the approach to sexual themes the girls displayed actually supports the determination that the conduct was inherently expressive.
This is where free speech gets really interesting, when it bumps against generational mores. The only thing "bad" about the speech was that the school officials didn't like it. Nothing else. Is that enough to allow the school to shut the kids down? No.

But what about the argument that the pictures affected the school or other girls by causing "divisiveness?" Isn't this kind of like harassment, or bullying, or intimidation, even if it is not as bad? Wouldn't the "pure" girls feel reluctant to play volleyball with a team of sluts?

Petty disagreements among players on a team... is utterly routine. This type of unremarkable dissension does not establish disruption with the work or discipline of the team or the school...Consider, for example. [the case in which] getting a phone call from a disgruntled parent, and evidence that a student temporarily refused to go to class and that five students missed some undetermined portion of their classes... did not rise to the level of a substantial disruption.
In other words, get over it. If you don't meet these girls in school you'll meet them in college or in their 30s in Indianapolis (the whole city is horny.) The fact that you have to avoid them or deal with them or sleep with them or argue with them is mostly your problem. I sympathize, sure, and I'm happy to help, but it's still your problem. You can't change other people, even if they are wrong.

III.

But wait a second: how did the school even see the pictures? Take a moment and come up with an answer.

...a parent brought printouts of the photographs to the [Superintendent]... The parent reported that the images... were causing "divisiveness" among the girls on the volleyball team... Separately, but on the same day... the principal was contacted by a second concerned parent, one who happened to work at the school as an athletic department secretary.

The school has a problem, and it isn't high schoolers wrestling with their hormones. The school is infested with rats.

The true social implications of this case aren't about the girls' behavior, but the parents'. To what extent are they allowed to impose their values on their kids, and, separately, what is the proper structure to impose these values?

This popular reading of this case is that the school (i.e. government) doesn't have the right to reach into the private home and control the speech of students, but that evades the important cause of this case: the parents want the government to control the kids because they aren't willing to do it. See? It's not just black kids. Parents all over the U.S. have checked out, can't be bothered and anyway don't really know how to bother. How can I explain to my daughter that this is bad? I know: Tinker v. Des Moines Indep. Cmty. School Dist. Yeah. That'll show her.

The way it should have worked is that one concerned mother calls the other mother, and she opens up with, "I just want to bring something to your attention" or "Jesus, do you know what your wenchy daughter is up to?!" and they work it out and stuff gets handled, and if it doesn't it gets kicked to the fathers, who freak out on their daughters and then reluctantly agree to talk to the other father about it and settle it once and for all, and if that doesn't work they can agree to meet in the Woolworth's and Woolco parking lot and punch each other like girls. I recognize this is all quite sexist, but that's the way it should have gone down. That's the way it has always gone down.

But the parents couldn't handle this as parents, i.e. as the ultimate arbiter of a controversy, because they are not practiced at being the ultimate anything. Stripped of all power as children, and never given either power or responsibility, they drowned in freedom and looked for a practical solution to their existential crisis: everything always has a higher authority. Call the school, call the cops, call the government. The joke used to be, "hey, lady, don't make a federal case out of it!" but that's no longer a joke, it's the preferred method.

The idiocy of such parents is mind boggling, certainly, but even more compounded by the message that it sends to their own kids: higher authorities always exist for everything. Just not God. That's for stupid people.

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===== ====== ===== The Last Psychiatrist: What US v. Comstock Means To You

phew... won't be needing this anymore

Let's dispense with CNN-soundbite analyses of the case.

Washington (CNN) -- The U.S. Supreme Court ruled Monday the federal government has the power to keep some sex offenders behind bars indefinitely after they have served their sentences if officials determine those inmates may prove "sexually dangerous" in the future.

...At issue was the constitutionality of federal "civil commitment" for sex offenders who are nearing the end of their confinement...

Not even close. This isn't about sex offenders. This is the Supreme Court, not your local public defender/bench trial farce pretending to be justice. And it isn't "by extension" about the indefinite detention of terror suspects.

It isn't about whether it is ok to civilly commit criminals after they've served their time. This is something I am against, can argue it classically, drunkenly, or violently, your choice, but regardless, isn't really the point.

The question here was whether the federal government is allowed to engage in civil commitments for anything other than the enforcement of (federal) criminal law.   More generally, is the federal government allowed powers it thinks important, not explicitly granted by the constitution, but not specifically prohibited either?

And, is the Supreme Court going to let them?

The answer is, yeah, pretty much.

II.

Thomas, first two sentences of his dissent:

The Court holds today that Congress has power under the Necessary and Proper Clause to enact a law authorizing the Federal Government to civilly commit "sexually dangerous person[s]" beyond the date it lawfully could hold them on a charge or conviction for a federal crime. 18 U. S. C. §4248(a). I disagree. The Necessary and Proper Clause empowers Congress to enact only those laws that "carr[y] into Execution" one or more of the federal powers enumerated in the Constitution. Because §4248 "Execut[es]" no enumerated power, I must respectfully dissent.

All extra power that may be needed by the government is explicitly granted to the states. That's the whole Federalist set up. "The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states." That's the whole point.

The government already does lots of things outside its enumerated powers. It builds prisons. It can declare a quarantine. It gets away with these because they are closely related to actually enumerated powers.

The test is whether the desired power/law-- is "necessary and proper" and also "legitimate," as defined as "within the scope of the Constitution." But the two parts of the the test must be equally considered.

(Thomas) Unless the end itself is "legitimate," the fit between means and end is irrelevant. In other words, no matter how "necessary" or "proper" an Act of Congress may be to its objective, Congress lacks authority to legislate if the objective is anything other than "carrying into Execution" one or more of the Federal Government's enumerated powers.

You can be for Big Government or you can be against it. Whatever, it matters not a lick. It matters GIGANTICALLY that the supposedly conservative, strict constructionist Chief Justice, a man who had previously been in a tennis club actually called The Federalist-- has come down decidedly on the side of, "well, I guess in some cases it's ok..."

Say what you want about Scalia and Thomas, but undeniably, they are old. They will die. If they were the only two willing to put pen to paper against a government looking to expand its powers, look out.

III.

"The court's holding today is a victory on behalf of the American people," said Sen. Patrick Leahy, D-Vermont, chairman of the Senate Judiciary Committee.
"The process to enact this law to protect our children from those who would do them harm was difficult. I am heartened to see an overwhelming majority of the Supreme Court uphold this important child protection law."

Listen, dummy, you have it backwards.

All constitutional questions aside, the practical outcome of this is that it puts a criminal matter into the hands of the psychiatrists. Is that what you want? Worse: it places the prediction of a future crime in the hands of the psychiatrists. Worse still: it places the prediction of a future crime on the basis of not having actually committed any crimes yet in the hands of the psychiatrists. Note that one of the defendants didn't actually molest anyone, he only had child porn. Is hentai child porn? Well, it is now.

Is raping a child a mental illness? Not is it evil, not is it curable, I'm asking if it represents a discrete pathology? How is a psychiatrist to intelligently predict dangerousness there? What if he gets it wrong-- in either direction?

In an ordinary psychiatric commitment, I have to predict whether this guy's mental illness may cause him to be dangerous. Note carefully: not predict if he is dangerous, but whether that dangerousness is the direct result of a mental illness. If I think a guy is going to shoot a rival gang member, locking him in a hospital isn't allowed. So? He raped a child last week. He exhibited no signs of that behavior previously, and he doesn't have any now. So?

IV.

I've nearly had it with this country, with this generation.

Forget about being responsible for yourself, people are not even willing to be responsible for choosing someone else to bear the responsibility.   Don't bother me. So long as I can Facebook all night and not have to have sex with my spouse.

The government, not just Obama, Bush too-- is the manifestation of this narcissism and laziness. On the one hand, the government wants all the power in the world to do what it thinks is right, the other half of the country be damned. And we say, sure! just drop me off at Nordstroms, it's on the way.   On the other hand, anything it finds politically toxic it offloads to the group with no scientific rigor and no ethical framework beyond expediency. Got poverty? You can apply for welfare and disability down at the community mental health clinic.   Got criminality? They have a branch office in the jails, too.

Whenever you hear about Chinese schoolkids getting slashed or Japanese teenage hikikomori masturbating to bootlegs of The Ring, it seems only logical to wonder, hey, what's up with that crazy culture?

So I put it to you: you got an epidemic of pedophiles- or you have a media created fantasy of an epidemic of pedophiles; for which the government response in either case is a) more powers for us; b) more psychiatry for you.

What's up with that crazy culture?

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: What Was The Matrix?

What are you telling me, that I can dodge bullets?

I'm telling you that when you're ready, you won't have to.

(Part 1 here: An Action Movie Fairy Tale)

No, no, it doesn't end like this. Not like this. [she dies.]

With every passing day, you realize you will not fight bad guys, not join the CIA, not be in a band, not throw the winning touchdown.

You will not know kung fu.

Your body sickeningly, boringly confirms it. You breathe harder when you run. You don't run anyway. Hair missing, appearing.

Women your age are better looking than men your age. Wait, wait, what?

Hopes and dreams are now only dreams. You start to care about office politics because nothing else is happening. Clothes matter more because very little else does.

Drinking helps. You don't know why, you aren't an alcoholic, but you need it.

"I will never be in love." You love the sister you've married, but there's no hunger, no need. There never really was. This was supposed to be temporary until... she came along. The woman with the dark hair tied loosely in a bun, wearing a scarf, glasses, stunningly beautiful (no one had noticed her but you, of course)-- lost-- needing to be saved---

But wait, you're still young. Ish. You still have some time-- something could still happen.

What modern middle aged narcissist wants is to find a way to put one foot in reality and keep one foot in fantasy. A solution that lets him keep fighting the traffic twice a day. Providing just enough lack of self-awareness that he doesn't reach for a bazooka and blow his brains out. (If only he had even energy for that.) To have just enough hope that one day the fantasies could come true that he keeps on going. That a 30 something year old man could suddenly know kung fu.

Fortunately, we find ourselves at the tenth anniversary of just such a solution.

The Matrix: the natural, necessary end to the action movie generation, temporarily postponing a tripling of the suicide rate.

What Is The Matrix?

No one can be told what the Matrix is. You have to see it for yourself.

The Schizotypal State

It wasn't supposed to be like this. By this age, things were supposed to have happened for you. You were supposed to be somebody. Someone was supposed to have fallen in love with you.

What is called the "world" doesn't seem like what you thought it would be.... there's a lack of emotional connection; a lack of highs and lows, of change, of either growth or regression. No energy. There's no real love. Instead is trudging, boredom.... ennui.   There's nothing happening in your life; yet you feel like it's out of control.

Neo: I don't like the idea that I'm not in control of my life.
Morpheus: I know exactly what you mean. Let me tell you why you're here. You're here because you know something. What you know you can't explain, but you feel it. You've felt it your entire life, that there's something wrong with the world. You don't know what it is, but it's there, like a splinter in your mind, driving you mad...

You walk through life diligently performing the tasks assigned to you, automatically. But always the thousand yard stare, the tiniest expectation that it is all about to change. More than fantasy but less than delusion, you hold active the remote probability that you are more than your current appearance. You're not unfinished, you're undiscovered.

If, in the preposterous situation of alien invasion or talent scout or ninja attack, you'd know exactly what to do. You'd be able to do it.

It seems that you've been living two lives. One life, you're Thomas A. Anderson, program writer for a respectable software company. You have a social security number, pay your taxes, and you help your landlady carry out her garbage. The other life... where you go by the alias "Neo"... One of these lives has a future, and one of them does not.

It is the reverse of Nausea, it's Constipation. You have a completely defined, detailed identity, but it never got a chance to come out. The world wouldn't cooperate. The problem is the world.

You know you don't really know kung fu. You know ninjas aren't going to attack. But you know a secret: that the impossible thing is a ninja attack, not that you would know kung fu if ninjas attacked. In a reality which would permit the existence of a ninja attack, it is inevitable that it would allow you to know kung fu.

What kind of a reality is it that blocks impossible scenarios, but treats them as prerequisites?

Boy: Do not try and bend the spoon. That's impossible. Instead... only try to realize the truth.
Neo: What truth?
Boy: There is no spoon.
Neo: There is no spoon?
Boy: Then you'll see, that it is not the spoon that bends, it is only yourself.

A reality that is still, partially, under your influence.

The Anchors of the Schizotypal State

You say: but no one seriously believes reality is fake, that we're living in a computer. Correct; but the issue isn't the reality of reality, but under what circumstances would reality change for you? What are the necessary requirements for you to suddenly know kung fu?

God is one. God lets the world run as it is, but if ninjas attacked, God would make sure you'd know kung fu. But there's no religion here, you don't need to go to church for this, you just need to believe that God is watching out for you. This is why organized religion is in serious decline. There's no way a Catholic God will upload kung fu when you need it. Access to that kind of transcendent knowledge requires Buddhism, or agnosticism. It requires you not to know who He is, so you can make Him into whatever you need Him to be.

You're not going to subject yourself to His rules; you're going to subject Him to yours.

Do you remember the movies that had the Devil as the bad guy? The hero never had special powers; he had to perfectly execute Catholic rituals or incantations that exist independent of himself in order to stop the Devil. That was back when we still believed in something outside of ourselves. They don't make those movies anymore.

Credit is another one. No, credit won't change reality, but credit solidifies your identity in preparation for a change in reality.    Credit says: buy this coat, it signifies that you could know kung fu.

Girlfriends are another. Girlfriends say: I pretend to believe you when you say you know kung fu, because I love you. The boyfriend says, not hearing anything she said:   I'll stay with you until either I know kung fu; or you realize I don't really know kung fu, and my shame makes me hate you. What does it matter? None of this is the real thing anyway.

Some Lessons of The Matrix

1. Information Is Knowledge.

After a gunbattle, Trinity and Neo need to fly a chopper.

Neo: Can you fly that thing?
Trinity: Not yet. [Dials a phone.] Tank, I need a pilot program for a B212 helicopter.

Poof-- she now knows how to fly a chopper.

Fine: how did she even know that it was a B212 helicopter?

Presumably she learned it "on the job." But knowing that fact is pointless: none of it is real anyway, and Tank "sees" everything, he would know what programs to upload, she could simply say, "I need to fly that thing over there."

It's the accumulation of trivia, the same as a guy who learns all the different kinds of handguns but never shoots one; they know minute details of rock music, when something was performed, who produced it-- but never played an instrument. It is the substitution of information, easily acquired, for knowledge. Knowing about it makes you think you are so much closer to knowing it. But, as any virgin on the internet will know, knowing about and knowing are different things.

2. Love Is Waiting For You To Become.

Trinity loves Neo, even before he becomes The One. She's waited her whole life for him. He doesn't (yet) know kung fu, but she knows he will. And she does know kung fu-- and chooses him, saves him. That's love.

But Neo doesn't return the love until he becomes who he has always known he is. He has to know kung fu first.

Only then can could someone really love him.

3. Self-Identification Transcends All.

Agent Smith has Neo ("Mr. Anderson") in a chokehold on the train tracks; the subway speeds towards them. Agent Smith is-- satisfied.

Hear that, Mr. Anderson? That is the sound of inevitability. It is the sound of your death. Good bye, Mr. Anderson.

Agent Smith has it figured right: Anderson's life was a pointless struggle. All the dreaming and all the expectation are doomed to end in failure, in death.

Faced with the absurdity and unintelligibility of life, but the inevitability of its end, there is only one answer that today's man-- the narcissist-- can give that makes his life meaningful, and he gives it:

My name is Neo.

That's all he needs to say to escape the inevitable.

II. It's Just A Movie

Someone says: oh, come on. There's no real philosophy in The Matrix, it's homeopathic doses of Kant and Derrida.

HA!   What are you, German? No one's read Kant, what the hell is the matter with you? No one's even read A Christmas Carol. There was more philosophy in those two hours than people had passed in a bookstore over their entire lives.

If you're 50, you say: really? a movie is that powerful that it can affect the consciousness of people who didn't even like it?

I know, I know, such power is given only to the Beatles... or Pink Floyd... or the Dead... or On The Road. All these things are the same. They all say: stay young with me as your life washes away beneath you.

"But I didn't even see the stupid movie!" Look around: they did. It's enough.   Or did you buy an engagement ring because of three thousand years of tradition?

III. Narcissism Beats Reality, Again.

The Matrix was the articulated solution to a growing existential crisis. It gave us hope: "Unless there's solid reason not to, I'm just going to allow the possibility that there's more to reality than what I see, and so there may be a valid reason to hope that my real life will kick in any time. And then someone will love me."

I know kung fu.
"No, but when I need to, I will."

The Matrix could have carried us, could have kept the Schizotypal state active, maybe for another ten years. It gave Narcissism the strength to look reality in the face and say, "my identity is bigger than you, I don't care what you do, if I needed to, I could control you."

Two years after The Matrix, reality responded.

===== ====== ===== The Last Psychiatrist: What Would You Do If Your Fiance Gave You a Ring That Wasn't Good Enough?

lawyers are standing by

(Part 1 here)

Oh my God, what's he doing...
"Will you marry me?"

You cover your mouth with your hands. In a microsecond you saw the ring wasn't...

But in this moment you have to follow the script. Action.

INT. RESTAURANT - DINNERTIME.

GUY on one knee. GIRL looks shocked.

===== ====== ===== The Last Psychiatrist: What Would You Do If Your Fiancee Rejected The Ring As Not Good Enough?

now let's see what kind of man you are

"Will you marry me?"

She covers her mouth with her hands and looks shocked. Tears. Oh my God. She can't believe you did this. (Yes she can.)   She says yes. (Not like there was any doubt.) The other men in the restaurant join their wives in polite fake applause, albeit less enthusiastically. Congratulations, they say. They don't mean it.

Through dinner she turns her hand every which way. It's so beautiful. It's so clear. How many karats is it, is it ____? and the number she guesses will be off by one. Of course.

How much did this cost you? she eventually asks. Wow. How did you afford it?

Until finally.... It may happen at dinner, or at home, or... She says:

I don't want you to take this the wrong way

I really love it

But

I was kind of hoping for something a little

.... bigger.....

I.

Cue penis jokes: "She looks down and says, 'I was hoping for something bigger.'" Hack. If she cancels the sex because it's not to her standards then she's not just a bitch but a slut, and not just a slut but a psychopath, because she's reduced your existence to a heated dildo, nothing else matters to her because nothing else can matter to her. Sex is mutual masturbation.

II.

Assume this is a hypothetical scenario; i.e. imagine it happening.

The most important question for you, the reader, the one that will tell you the truth about what is happening in the story, is this: what does the hypothetical woman in this story look like?

III.

I was listening to Cosmo Radio-- what? I'm allowed-- and Patrick, the host, is discussing this hypothetical story. He had a strong reaction to it: "you dump that vapid bitch." I'm paraphrasing.

The thing is, this isn't the first time you two have been around each other. You have a prior history, you have had other insights into her character, you already know what kind of a woman she is. Which makes you the type of man that is attracted to the kind of woman who would say that. Uh oh. And guess what type of man that kind of woman is attracted to. You.

Patrick was right, you should dump her. But not because she's shallow, but because you are.

IV.

His co-host, Lea, didn't say much, and I got the strong feeling that she felt, hypothetically, it was totally ok to turn down a ring she didn't think was big enough.

Some women will say the ring is an expression of love, it reveals how much her man thinks she's worth. It shows to what extent he'd be willing to take care of her. What they mean is that the ring is a kind of test of his love: does he love me so much that he's willing to "waste" money, abandon practicality, when it comes to me?

I get that there are more sensible women out there, the point here is not a critique of the woman's logic, the point here is the man's.

The truth is that you knew when you bought it whether the ring was what she wanted. What you were banking on is that she'd accept it anyway. It was a kind of test of her love.

That's why this offer of the less than "perfect" ring that she rejects can be understood to be a defensive maneuver: you don't want to marry her. "You know what, you're absolutely right." Not so fast. I mean you'd be much happier just dating her, living with her, status quo. And you know, if she just waited, someday, someday, someday, you'll be rich; and then you'll buy her a really nice ring.

Yummy. Nothing the kind of woman looking for a perfect ring now wants more than a wait-and-see guy. You're with her (partly) for her looks, yet you expect she'll gamble those looks on a single horse race that starts sometime in 2025. "Don't sweat it, baby, I got a system." Can't wait.

But if your patent/stock/novel/horse comes through and you later do indeed get her that bigger ring, are you going to spend a greater proportion of your wealth on it, or just more money? If not, then you haven't properly understood what that ring represents to her-- crazy or not-- which means that you don't understand her, which means, importantly, that you do not care to try. The point here isn't that she's right, the point is you two are not connected.

Save your money. You'll lose it in the divorce anyway.

V.

I don't know if Lea would reject such a ring or not. Her hypothetical position is that a ring is a symbol and blah blah blah. In real life, she might reject such a ring, or circumstances with her fiance might be that she is perfectly happy with that ring, or any ring, or waiting for a ring, or who knows what, because the difference between what you would do hypothetically and what you would do in real life is the other person.

Hypotheticals like this can only be answered because you're controlling for the most important and limitless variable, the other person. When you have a real fiancee, who knows what you'd do? If you really knew her, the story wouldn't happen. So the point of these hypotheticals isn't to determine a code of behavior but to broadcast to others something about yourself. "I'm the kind of guy that wouldn't tolerate such a gold digging bitch." Oh, you're a Capricorn. But in your own hypothetical, hadn't you already tolerated her for a year? 40% of the time from behind?

In the example above, what did she look like? You imagined her to be hot.....ter than you. You did this because only a really hot chick, a kind of woman, would reject a ring because it wasn't big enough. And in this way you have justified not being with this woman, "a bitch!"-- a woman who doesn't exist but serves a a proxy for a type of woman who also does not exist-- so that you don't have to face rejection. In other words: blame it on the ring.

When the woman in the joke rejected you because of your penis, do you really believe she liked you except for the penis?

These hypotheticals are dreams. The lesson isn't what you would do; but how did you construct the fantasy to allow you to do it? That tells you who you are.

VI.

"Are you saying I have to buy her an expensive ring?" No guy wearing Axe who doesn't read the post before yelling. I'm saying that if you spring a ring on a woman which you already know is less than what she wanted, hoping that she'll be satisfied but not sure if she'll be satisfied, then the problem isn't the ring, the problem is you.

---

Now go here: What Would You Do If Your Fiance Gave You A Ring That Wasn't Good Enough?

http://twitter.com/thelastpsych

Is The Cult Of Self-Esteem Ruining Our Kids?

The Effects Of Too Much Porn

------

Notes:

1.

If you want the history of engagement diamonds, Epstein writes the classic. It reveals the extent to which our social constructions are.... constructions. Highlights:

"To stabilize the market, De Beers had to endow these stones with a sentiment that would inhibit the public from ever reselling them."

So began engagement rings for the masses. It all started in September of 1938.

The ad agency of N.W. Ayer started "a well-orchestrated advertising and public-relations campaign [to] have a significant impact on the "social attitudes of the public at large and thereby channel American spending toward larger and more expensive diamonds instead of "competitive luxuries."

...the advertising agency strongly suggested exploiting the relatively new medium of motion pictures. Movie idols, the paragons of romance for the mass audience, would be given diamonds to use as their symbols of indestructible love....

Did it work?

Toward the end of the 1950s, N. W. Ayer reported to De Beers that twenty years of advertisements and publicity had had a pronounced effect on the American psyche. "Since 1939 an entirely new generation of young people has grown to marriageable age," it said. "To this new generation a diamond ring is considered a necessity to engagements by virtually everyone." The message had been so successfully impressed on the minds of this generation that those who could not afford to buy a diamond at the time of their marriage would "defer the purchase" rather than forgo it.

2.

Off topic, but there's a masturbation competition in the US and Europe, and the world record holder went 9 hours.   Yes in fact, he was Japanese.

But the interesting thing about such a competition is that it exists. No shame in masturbating, I guess. "Why should there be? We all do it." My mom doesn't. I'll kill you.

But the lack of shame isn't what's really interesting. What's really interesting is that the purpose of it is to masturbate together. A previously shameful, previously solitary activity now done with other people proximate to you, but no connection is needed or even desired; the only goal is the self-pleasure, with the pretense of the camaraderie if the other skin jobs next to you.

I could say that it's a metaphor for social media, or narcissism, but it isn't a metaphor, it is the inevitable conclusion.

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===== ====== ===== The Last Psychiatrist: What You Need To Know About The MAOI (Selegiline) Patch

You've probably already read quite a bit about the selegiline (L-deprenyl) patch (right?), but these four (five) points may frame the information more usefully.

1a. All the oral MAOIs you are used to (phenelzine, moclobemide, trancylpromine, etc) are either nonselective (both MAO-A and MAO-B inhibitors) or are selective MAO-A inhibitors.

1b. MAO-A inhibition is needed for antidepressant effect.

2. MAO-A metabolizes serotonin, norepinephrine, dopamine, and tyramine.

3. MAO-A in the gut is what metabolizes tyramine. Inhibition of the gut MAO-A allows tyramine to enter the circulation unmetabolized-- thus releasing norepinephrine and causing hypertensive crises.

4. Oral selegiline (pill) is an MAO-B inhibitor at doses less than 10mg/d.

In other words, a) selegiline requires no dietary restriction below 10mg/d (because it doesn't affect MAO-A in the gut) and b) it doesn't work below 10mg/d (for depression; MAO-B metabolizes dopmaine, so selegiline will still be good for Parkinson's at small doses.)

5. Above 10mg/d, selegiline is nonselective (thus MAO-A and B inhibition). Thus, a) it should work; b) it will require dietary restrictions.

One interesting point: selegiline is rapidly metabolized (first pass) to desmethylselegiline, l-amphetamine, and l-methamphetamine. (1)

The point of the patch is that it bypasses the first pass metabolism (you don't eat it) so you get much higher concentrations of drug into the CNS and few metabolites. Also, much less goes to the intestinal MAOs, so you get both MAO-A and B inhibition in the brain, but less of the MAO-A in the intestine. So even if you use doses greater than 10mg/d, you (probably) don't need dietary restrictions. (NB: even though I can't find any studies clearly linking the risk (most find it safe up to 20mg) the PI still says to avoid tyamine foods above 9mg/d.)

Part 2: Efficacy

Above, I made the outrageous statement, "it doesn't work below 10mg/d." What's really outrageous is that I couldn't find any evidence that it worked above 10mg/d, either.

Here's a typical example: a 2003 study of 289 patients, double blinded, placebo controlled, of selegiline patch 20mg/d (keep in mind, the starting dose is 6mg/d) vs. placebo patch. Though the paper finds "statistical superiority" of the patch over placebo, it took 8 weeks to get a 2-3 point difference on the MADRS or HAMD-28. (For context: the HAMD-28 has 28 questions with ratings from 0-4. So three points difference could be three points on one question, or one point on three questions...) It never beat placebo on the HAMD-17. (To the author's credit, he does not hide this and is upfront that these were "modest" differences.)

Contrast that with the first clinical trial of the selegiline patch (done, astonishingly, by the same author): superior efficacy on all three scales. But, of course, even at 20mg/d, it's really not that superior:

Maybe 2-4 points, max? I grant more people responded to the patch (as defined by reduction of 50% on the HAM score)-- but it was 15% more people, and, well, come on on...

Just to make the point, a 67 person, multicenter, double blind, placebo controlled study tested oral selegiline's efficacy in schizophrenics, and found improvement vs. placebo in "negative symptoms," as defined by the Scale for theAssessment of Negative Symptoms (SANS). Troublingly, "improvement" means one point difference:

And not much happened for depression (HAM-D) either.

Someone, somewhere is going to accuse me of only showing weak studies and omitting all the studies that showed it worked well. Okay. Here is the last known study:
The only other patch study was a 321 person, 1 year long placebo controlled study, found that while twice as many people dropped out for side effects (13.2% vs. 6.7%), twice as many on placebo relapsed at 6 months (16.8% selegiline relapse vs. 29.4% placebo). Interestingly, at one year the relapse rates for both drug and placebo were identical-- in other words, all relapses occurred in the first 6 months, none in the second 6 months.

That's it.

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===== ====== ===== The Last Psychiatrist: When A Culture Is This Invested In The Lie, The Culture Is Finished

what does ~~the author~~ all of us want to be true?

The title of the article is called, How To Spot A Narcissist, and it is similar to thousands of such articles about narcissism by being exactly the same thing.

Here are some sentences from the article, taken entirely at random, see if you can detect the theme:

Narcissists will be thrilled to hear that as a group they are rated as more attractive and likable than everyone else at first appearance...

Tucker Max and his ilk stoke our attention and our ire --sometimes in equal measure. They are a decidedly mixed bag; therein lies one of the many paradoxes of narcissism...

Women who score high on tests of narcissism consistently dress more provocatively than their more modest counterparts; male narcissists resort to displays of wit and braggadocio...

A cross section of the narcissist's ego will reveal high levels of self-esteem, grandiosity, self-focus, and self-importance...

Erica Carlson and her colleagues found that college students scoring high in narcissism rated themselves more intelligent, physically attractive, likable, and funny than others, as well as more power-oriented, impulsive, arrogant, and prone to exaggerate their abilities!

How can narcissists maintain their inflated self-image even though they know how they are perceived by others?

In the sexual realm, promiscuity is a key strategy that allows narcissists to maintain control...

And it closes with an offer to self-test using the Narcissistic Personality Inventory. Go ahead, take it. Let me guess: you scored low.

Of course you did.

II.

Whether the article is technically accurate is besides the point, the point is why it exists, why they all exist.

Read the article: who is a narcissist? The narcissist is the other, the unattainable other. It opens with Tucker Max, who has had lots of sex with beautiful women. Since you chose not to be able to have lots of sex with beautiful women, you aren't a narcissist, which is some sort of consolation prize, I guess. Enjoy your Netflix queue.

All of the photographs, except one, are of super hot, super sexy women.

Are you a super hot, super sexy woman? No, you're pretty, but you're not so obsessed with your looks. And you're obviously smarter than her. Phew. You're not a narcissist. You can go back to torturing your boyfriend's soul.

Narcissists thrive in big, anonymous cities, entertainment-related fields (think reality TV), and leadership situations where they can dazzle and dominate others without having to cooperate or suffer the consequences of a bad reputation.

Not you? You should stop wearing deodorant, it masks the delicious empathy.

There is one picture is of a man:

and it seems abstractly arty enough to be a reasonable depiction of narcissism, except this is the title of that photo: man looking at his reflection in a broken mirror. Oh, so it's the mirror's fault. If only this shirtless Effexor success story could get a quality mirror, then he could see himself the right way. (Who wants to go po-mo?: note that the hot chick has a perfectly good mirror.)

There is one other photo of a man and a woman, both looking at themselves in hand mirrors. Get it? That's not you, right?

The photo is a deliberate lie of their/your unconscious. If you want that to be technically and psychologically accurate, if you want to rock your ego, the proper depiction would be each one looking at the other person's reflection in the mirror.

Because a real narcissist doesn't see himself, he sees himself reflected back by the other person. Is this chick correct enough to be the kind of woman that the kind of man I want everyone to think I am would be with? "What?" I know it's hard, but you have to do the work.

III.

The article, like the thousands of others, offers explanations as to why we're often attracted to narcissists. (NB: that must mean you're not a narcissist.)

They're "attractive," "extroverted," "talented," "dominant".... and maybe these things are true and maybe they are not but the reason they are mentioned is the same reason there are always obligatory references to evolutionary psychology, so that you can say: you were tricked, you were seduced, you were manipulated, as if you had no responsibility in the matter.

You think you chose your partner for the good qualities and the bad ones are baggage; but you chose them both because they fit your needs. That the relationship later failed didn't mean you were getting something from it. "Blaming the victim!" I'm not blaming the victim, I am observing a universal rule: the common denominator in all of your failed relationships is you.

I've written well over a hundred words about who is or isn't a narcissist, not to out them but to force you into the condition of self-reflection, to force you to ask, "do I do this to other people?" Is this me?"

My next sentence was going to be, "spotting a narcissist won't do you any good," but even that statement is a hedge. The spotting is a deliberate defensive maneuver. "That guy, and thus not me!"

Spotting a narcissist will get you nowhere because the problem isn't the narcissist, the problem is you.

---

Read this: A Generational Pathology

===== ====== ===== The Last Psychiatrist: When CGI Porn Looks Real: Is Anyone Thinking About The Children?

Making the internet rounds is a post written by Debbie Nathan, (Pornography: A Groundwork Guide and Satan's Silence: Ritual Abuse and the Making of a Modern American Witch Hunt) on what the government is going to do when computer generated child porn becomes indistinguishable from actual photos.

Other than freak out.

I.

Traci Lords makes several porn movies until 1986 when it is "discovered" that she was underage. So they go after the distributor, X-Citement Video.

Open and shut case-- they have her on film being underage and naked, so...

But on appeal, the 9th Circuit reverses the conviction. They say that the law is unconsitutional. It goes up to the Supreme Court, who reverse the reversal, and, more importantly, decide that the law is not unconstitutional. It is a great day for democracy, and for decency, but for the simple fact that they were wrong.

See if you can spot why that is:

Protection of Children Against Sexual Exploitation Act of 1977 (18 U.S.C. §§ 2252)

(a) Any person who -
          (1) knowingly transports or ships in interstate or foreign commerce by any means including by computer or mails, any visual depiction, if -
               (A) the producing of such visual depiction involves the use of a minor engaging in sexually explicit conduct; and
               (B) such visual depiction is of such conduct

The key word is knowingly. Knowingly what? Knowingly transports an object which [turns out to be] child porn. Not: transports an object knowing that it is child porn. Get it? Following this reading, the UPS guy is guilty of transporting child porn.

The Court acknowledged that that is the "most natural reading" of the law, but since it could lead to "absurd" results, they decide to interpret it differently, the more "logical way"-- instead of disposing of the law and forcing a new one.

"Well, duh, everyone knows what was really meant by the law." Really? One can easily imagine a time (say, now) when we all decide to read it differently, where the government looks for ways and laws to catch anyone it deems undesirable. Right? That could happen? I'm not just a paranoid, right? Such laws become, for example, deterrents on actually protected speech. For example, in this case it could be used to slow down all pornography.

Oh, wait, that turns out to have been precisely why the law was written that way in the first place:

In fact it seems to me that the dominant (if not entirely uncontradicted) view expressed in the legislative history is that set forth in the statement of the Carter Administration Justice Department which introduced the original bill: "[T]he defendant's knowledge of the age of the child is not an element of the offense but . . . the bill is not intended to apply to innocent transportation with no knowledge of the nature or character of the material involved." S. Rep. No. 95-438, p. 29 (1977). As applied to the final bill, this would mean that the scienter requirement applies to the element of the crime that the depiction be of "sexually explicit conduct," but not to the element that the depiction "involv[e] the use of a minor engaging" in such conduct.
So the intent wasn't to get the UPS guy, but it also expressly didn't want to make knowing the girl's age part of the offense, just that you know it's porn. The idea was to scare everyone down the pornography chain-- producers, distributors, etc-- to force them all to be more attentive to the possibility that their porn is child porn. Or not to make porn at all.

The real question brought up in the dissent was why the law even needed scienter (knowledge) of minority. Does forcing cinematographers to make sure everyone is over 18 really dampen free speech? To even debate the scienter requirement is to give it legitimacy that it doesn't have in these situations. This is pornography, not art-- why not force everyone to make very sure that the participants aren't minors? Otherwise it's perfectly legal to distribute child porn from Thailand ("there's no way for me to check, we don't even know who the actors are, and they told me they're all adults.") In other words, instead of debating where the word "knowingly" goes, get a law that doesn't have it in there at all: if you' can't show that everyone is over 18, you can't distribute it.

You may be surprised-- or not-- to learn that the dissenter in this case Antonin Scalia. Certainly he is not pro-pornography. But a) you can't have laws like this, vague and poorly constructed, talking around the issue, so that any government can choose to implement it any way it wants, and b) you can't allow the Supreme Court to basically re-write it, to suit their particular inclinations. You want a better law? Go ask Congress.

The Court today saves a single conviction by putting in place a relatively toothless child pornography law that Congress did not enact, and by rendering congressional strengthening of that new law more difficult.

II.

Back in the 1997(?) Patrick Naughton, an executive at Infoseek (where?), gets on dad&daughtersex and chats up a 13 year old girl named KrisLA, and agrees to meet in her home state. Surprise! She's a 40 year old guy who works at the FBI.

Naughton says he really "knew" she was an adult woman, and anyway all the pics found on his computer are computer generated. He's found guilty of possession, all other counts result in a hung jury. (All men voted not guilty, all women voted guilty. Does that beg the question: jury of your peers?)

Less than two days later, the 9th Circuit Court independently decides Child Pornography Prevention Act of 1996 is unconstitutionally broad. He is released.

The Child Pornography Prevention Act of 1996 (CPPA) 18 USC 2256, says, awesomely:

(8) "child pornography" means any visual depiction, including any photograph, film, video, picture, or computer or computer-generated image or picture, whether made or produced by electronic, mechanical, or other means, of sexually explicit conduct, where--
    (A) the production of such visual depiction involves the use of a minor engaging in sexually explicit conduct;
===== ====== ===== The Last Psychiatrist: When I Get Writer's Block, You Get This

ART THOUGHTZ: Post-Structuralism from Hennessy Youngman on Vimeo.

There may be some inconsistencies in it. But that pretty much depends on you.

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===== ====== ===== The Last Psychiatrist: When I Said Doctors Were Too Involved In Social Policy, This Isn't Exactly What I Meant

"Seven of the eight people arrested are doctors or medical students..."

No psychiatrists, but it's only Tuesday.

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===== ====== ===== The Last Psychiatrist: When Is It Okay To Rape A Woman?

no one's gonna hear nothing

I think I'm supposed to put up a *PTSD triggers* warning, so consider yourself warned.

I.

On the Ron and Fez show, an male intern asked: if you could rape a girl, but then give her this magic drug that left her with no memory of the rape, would you do it?

Such hypotheticals are often argued over beers and best settled over rum, but the real learning isn't in the answer but in the asking of the question.

His argument was that since there's no evidence that it happened and she can't remember it, then she can't possibly suffer the consequences of it. So, no harm done. And the response to this is that there's a reality outside of perception, and whether she suffers or remembers doesn't much excuse the act. Rape is rape. End of story.

But it's right about there that the question gets more interesting.

II.

Without even answering the question, it's important to understand what the intern did: he assumed that most of the (male) population would (want to) do the same. He didn't think men would all rush out and do it-- and he was protected from finding out because such a magic pill doesn't exist-- he believed that in men's hearts, when they consider the world of fantasy and what they wish they could get away with, men would want to get away with this. We all wish we could just bang that girl and then erase her memory.

A caller incorrectly identified this as the consensus fallacy. A consensus fallacy is the assumption that since lots of people believe it, it must be true. But in our case the intern's mistake was in assuming that lots of people agree, which is false. The actual fallacy is called the false consensus bias, in which one assumes others share the same beliefs as you do.

I make this distinction explicit because it should be evident that two different kinds of people will be prone to either error. Some will hold, as their premise, what many already believe; and others will PROJECT what they believe onto others.

Importantly, no amount of data or solid evidence will convince the latter-- the false consensus bias guy-- that he is wrong. That's because it's not a belief, it is a maneuver, it is an act to protect the self, an act that they will take as far as they need to. "No, they're lying, they're just not willing to admit it." When you hear that-- "I speak for others who are too frightened"-- run; because if they had a gun, they would speak for you.

III.

In physics, you typically solve an equation by getting it into the form of a different equation that's already been solved. So the Rape question is of the form "if a tree falls in the forest, and no one is around to hear it, does it still make a sound?" Solve for x: duh.

Not so fast, Sir Charles, technically, the answer is no. The question doesn't ask if the tree fell or not, but if it made a sound. The felled tree generates (real) air pressure waves that we call sound waves, and these pressure waves hit the ear machine and are interpreted as sound. The tree doesn't make a sound, we interpret what it makes as sound. A creature with no ears might experience these waves differently, Beethovening them as vibrations on it's body.

So now our rape question is, if a penis goes inside a vagina, but no one's around to remember it, is it still rape?

The intern says that as long as she never finds out, she can't judge it as rape. He's arguing that moral questions ("this is rape/ this isn't rape") are different than technical questions ("I penetrated her/ I didn't penetrate her.") There's no such thing as objective morality, society merely agrees on some rules-- and since she can't remember, she can't judge it.

Fine; but he is a person, and he remembers it, and he was there. So it is still rape. He might try and rationalize that he doesn't think it's rape, but then he'd be lying: the question he asked used the word rape.

One of the biggest mistakes we make when arguing with dummies is that we don't take their own words at face value-- we allow them pretend that their initial move was meaningless in comparison to the revisions, like a bank robber who says to the police, "yeah, but I'm giving it back right now." The initial volley is always the most relevant: everything afterwards is defense.

IV.

But there are some of you who will agree with the intern. Some of you will wish you could-- not that you'd ever do it, but boy oh boy wouldn't it be great. It's to them I'm writing.

The intern, and you, don't even need to have performed this rape; simply by answering the question in the affirmative, your lives have veered sharply to the left, you have made connecting with another person substantially more difficult. By which I mean impossible.

V.

If you could rape a girl, and then give her a magic drug that would leave her with no memory of the rape, would you do it?

In responding to the intern, Ron (the host) made an obvious point, and before I make it I want you to clear your mind and imagine yourself acting out this scenario. You're a man, on top of the woman, finishing, pulling out, and then giving her the drug. She blinks, looks at you like she forgot what she was going to say, and goes back to ringing up your order.

Got that image? She doesn't remember anything. She's perfectly happy, no harm done at all. The point Ron made was, "so if a couple of my boys from the west village rape you in the ass, and inject you with the drug, that's ok?" He used the word "fucking" to modify every noun in that sentence, but I'm paraphrasing.

Some of you are right now experiencing a weird disconnection. Like the intern, that obvious thought simply hadn't occurred to you. And it wakes you up to the reality of the rape, of course this rape is wrong. Forcing you to imagine yourself as the victim makes the scenario more real, more vivid.

But why it didn't occur to you? Are you a bad person? Selfish? Homophobic? Why is imaging yourself as the victim more real than imagining yourself as the raper, even though that was the intended fantasy?

Because picturing yourself exerting power is fantasy; imagining yourself as victim is easy. Which is why you brought this all up. You spend a lot of your waking life creating elaborate fantasies of power that contain their own self-justifying logic, and those fantasies are so numerous that added together they actually take up a real portion of your day. A portion you're not spending on something else. If I saw a Tardis, then I would know how to pilot it. If such a drug existed, then my sexual problems would all disappear.

What you don't see is that this logic isn't even self-justifying, it is self-destructing. Not "since I have sexual problems, I wish I had the drug"; but, "since I wish I had the drug, I have sexual problems." Since I wish I had the drug, two hours have already gone by. I'm staying in tonight.

VI.

How could you live with yourself? Guilt without shame, that's how. Guilt without shame, for you, is no guilt, because what you did isn't who you are. You're a good person. How do I know? You told me yourself.

You can imagine yourself getting raped by the West Village guys, and that's really vividly bad. Imagining what she must feel when you do it to her-- that's really vaguely good. How easy is it to empathize? Easy. How easy is it to sympathize? Not so easy.

VII.

No one can hear us. So level with me: just because it's wrong, doesn't mean you wouldn't still do it. Right?

The intern, in a pseudo-devotion to his premise, said that the west village ass raping scenario is a go under his logic. Maybe, maybe not, but what he was really thinking was, "I know it's wrong, I don't want it happening to me, but if I could do it to someone else, I might still take the chance." Stealing is wrong but if the leprechaun is off dancing a jig you're going to shimmy down indigo and make off with his Lucky Charms.

In your defense, violating a rule is much healthier than thinking the rules don't exist. So you're not lost, you can still change your life. But it's lonely. There's no one else in it.

VIII.

"If a tree falls in the forest, and there's no one around to hear it fall, does it make a sound?"

The question itself is explicitly a question about sound, but we wield it to make a point about objective reality. We want it to be about reality, fine, but that's because the objective reality question seems open to debate while the scientific one is not, and so we alter the question's intent to get to where we want to go.

So the way we choose to hear the question says a lot about what we believe to be true or important, even without answering the question.

Let's re-run the scenario. On her, in her, out of her, drug her. She blinks her eyes, smiles, and goes back to cheerleading practice none the wiser. End scene. That about right? Okay, question: was she crying?

The scenario is about a magic drug that makes her forget. But how on earth do you plan on getting your penis inside her before that? How are you going to get an erection strong enough to penetrate a woman who is crying in terror, not to mention resisting? The reason you're even imagining this is because you feel like you can't get her through seduction, so you still have the mechanical problem to contend with.

I agree that a dangerous minority want this fantasy to be about violent rape, and I agree that it's easy to spot those guys because they all have mustaches. BUT the majority are imagining... come on, think hard, get into the scene, you are imagining that she likes it. Maybe you imagine her partially drugged (though that wasn't part of the premise, was it?) but by the end of it, she's into it.

That's what makes this premise so bizarre and so revealing. If she enjoyed it, you wouldn't bother with the forgetting drug. What he is imagining is that she'll want to have sex with him and then forget; but what he said-- what we've run through for several paragraphs-- is that he wants a drug to make her forget.

Squirm, wildman, squirm. "No, what I meant was..." And it starts, the minor adjustments to the original question, e.g. "well, the drug could be for the times when you know you could totally bang your wife's sister but who needs all the drama later?" Fine, but admit you just made that up now. That wasn't what you were imagining.

And so on, a million of these amendments and appendments and defendments to the original question that you say are clarifications, but they're all defensive, they are post hoc rationalizations, they are diversions. The true form of the question you are asking is, "does the ability to give a girl a forgetting pill afterwards give you the courage to try and hook up with her?" Which simplifies to: "can you live with rejection?" Solve for x: duh.

IX.

The argument here is that you would rape her as long as she wouldn't remember it or suffer, but it reveals how little you are able to perceive the complete existence of others that you would even consider using them as a prop. I can confidently predict a gargantuan amount of rage in you, which you will assume is completely unrelated. You'd be wrong. They are the same force.

The interesting thing about where you have found yourself is that it is easy to fix, but as usual the focus has been backwards, on you and not on what you do. While the question reveals a lot about you, it also causes you to think and behave a certain way. Though it's a fantasy that a pill can solve your problems, your mind includes it in weighing your next real moves. You are less likely to approach that girl at the DMV because your mind has found a safer way (for you) to handle it. That "less likely" may only be a dyne of force, but it is not nothing.

Now think about how many fantasies and scenarios you're actively running every day about a million things, and think about how many of those things you're actually attempting in real life. I know the popsicleogists will say you're running the scenarios to make yourself feel better, but they are what's holding you back. Those thoughts, in the absence of any action, have defined you.   Just because no one else can see it, doesn't mean it didn't happen.

---

You might also like:

Did The NPR Chief Have A Liberal Bias?

Ready To Go, Even For Nonconsensual Sex?

===== ====== ===== The Last Psychiatrist: When Lilly Pays Out $800M, Where Does That Money Go?
It's easy to get confused by big numbers and health care reform by subterfuge.

[Judge] Kelly immediately imposed sentence, ordering [Lilly] to pay $615 million, including a criminal fine of $515 million and $100 million in forfeiture.
Not for me to judge the criminal sentence. Next:

The charge against Eli Lilly was announced earlier this month simultaneously with a civil settlement in the amount of $800 million. The total monetary settlement totaled $1.415 billion.

What civil settlement?

In the civil settlement agreement, Eli Lilly agreed to pay the United States approximately $438,171,543.58 to settle allegations that it caused invalid claims for payment for Zyprexa to be submitted to various government programs such as Medicaid, TRICARE, [etc] for unapproved off-label uses. Also, Eli Lilly agreed to pay various state Medicaid programs more than $361,828,456.42 to settle similar claims.

A.

First, an aside: why is it called "Zyprexa" in legal documents but "olanzapine" in medical journals? Is anyone fooled by this? This idiocy also extends to reporting about the drug: Psychiatric Times, same issue: FDA considers pediatric labeling for olanzapine; Lilly Off-Promotion of Zyprexa.

Richard when he gives you money, Dick when he doesn't, I guess.

B.

So $800M gets paid to the government because Lilly caused doctors to write Zyprexa off label.

Think about this. I'm not arguing the sentence. If the government simply wants to create a law that says off-label promotion is subject to a billion dollars in penalties, ok. Again, I'm no judge.

But under what logic can the marketing Zyprexa off- label be considered causing a false claim for payment? This isn't a clever legal trick: the False Claims Act is the explicit mechanism for policing off-label promotion.

Yet it's lunacy.   The doctors wrote the script. Therefore it can never be a false claim, unless they're accusing the doctor of making the false claim, which they're not. If a doctor saw in a dream that Lipitor can calm an agitated demented patient and they try it, that's not a false claim. It's probably not even negligence.

The reason this matters is that we are in America, not Greece, or Spain, or Russia. Either we're upholding the law, or we're devising stratagems to go after whoever is currently politically unpopular. How you police something is more important than catching bad guys. This is why cops can't plant drugs on a suspect that they know is guilty. Right?

So if you're saying that Lilly caused doctors to unknowingly file a false claim, then you have to pick between one of these two choices:

a) either doctors were actually deluded by Lilly and thought that Zyprexa was FDA approved for "agitation in dementia," in which case it is very likely that their entire medical practice is one gigantic false claim; or

b) they knew that it was not approved for that, but were convinced by Lilly's marketing that it might actually work for that, so they prescribed it.

If you chose b), it should be immediately obvious that Lilly "caused" only Day 1 of the Zyprexa Experiment; everything else after that was the doctor's determination of whether it was working, worth it, etc.

Before anyone argues with me, understand what's at stake: physician autonomy. Anything that "causes" doctors to do something against their will or judgment; anything that "helps" physicians "practice better"-- all of these things presuppose that doctors are not able to figure things out for themselves. So then why have doctors in the first place? You may as well boot up a few Prescribatons and upload the Texas Algorithm 2.0 and let them medicate the consequences of the rest of the government's failed social policies.

Why resort to saying that off-label promotion is bad because it does something to doctors instead of saying it is bad in and of itself?

Oh: because when the government says a doctor was caused to do or not do something, what's soon to follow is the government telling a doctor to do or not do something.

Also interesting/horrifying, is this allegation:

Eli Lilly trained [its reps] to promote Zyprexa by focusing on symptoms, rather than FDA approved indications.

If we can just put aside our hatred of Big Pharma for one second, can anyone explain the difference between "symptoms," and an "indication" having no other objective characteristics except those symptoms? Oh, I hear the arguers clicking the caps lock. Be careful what you wish for. Would it have been better if doctors were "taught" to recognize "dementia related psychosis" as a schizophrenia-spectrum disorder? Oh, like you can tell them apart on MRI? Dementia praecox, after all.

I may be quick to point out the idiotic things doctors do; but none of those things, none of them are more idiotic than the things doctors are told to do, under the pretense of science (e.g. clinical guidelines) or the law.

C.

BTW:

The qui tam relators will receive $78 million from the federal share of the settlement amount.

Those would be the 6 or so former reps turned whistleblowers. No honor among thieves, or something.

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===== ====== ===== The Last Psychiatrist: When Was The Last Time You Got Your Ass Kicked?

the problem is that the answer is never

On <i>Louie</i>, super-comic Louie CK and a date end up at a late night donut shop. Five teens roll in, obnoxious and expansive, and Louie turns and tells them to keep it down.
One teen comes over and threatens Louie. He does it in the pseudo-friendly, control the conversation way that is 100% the sign of someone trying to size you up; the longer it goes on, the more sure he is.

30 second clip tells you all you need to know:

"Hi, my name is Sean. What's your name?" And extends his hand.
Louie sighs. "Nice to meet you," he says resignedly.
"'Nice to meet you?' Is that your name? 'Nice to meet you?'"
"No, it's Louie."
"Oh, Louie. Hmm. Hi, 'Loo-ey.'" [Smirks.]

Etc. It escalates to threats, "tell me, Louie, how long has it been since you've had your ass kicked?" and ends with the kid forcing Louie to beg: "Please do not kick my ass."

Right before he leaves, the kid says, "that was painful to watch."   He's right.

II.
The whole mess is complicated/dominated by the presence of Louie's date.   What's a chick going to make of this?   The scene concludes: Louie's date says, "mentally I know you did the right thing by not fighting, but emotionally, primally-- that was a turn off. That was pretty humiliating, watching another guy dominate you like that."
Let me amend that: what would a guy think a chick is going to make of this?

III.
Louis CK is prime timingly perceptive about men; but he's way off about women.
On the one hand, you get no points for beating up a 17 year old; on the other hand, points off for getting beaten up by a 17 year old. Using this scoring, Louie should have clocked him. But then there's that whole jail thing.
But there's the secret deduction: points off simply for allowing a teen to bully you for ten minutes.
"Well what would you do?" I'm asked as if what a misanthropic rummy would do and what you should do are even compatible. But they're asking about the date: "I don't want to humiliate myself in front of her. I don't want her to think I'm not a man." Ok, so fight. "Well, I'm being honest here-- I'm not a fighter."
America isn't obsessed with sex and violence; it's obsessed with authenticity (or avoiding it). It just so happens that sex and violence are the only two things that you can't fake, and we keep coming back to them as the definitive "measures of the man." We can fake wealth, intellect, status, kindness, political acumen, parenting, looks-- there's no objective measure of any of these things, a man can construct any identity he wants, people might not buy it but who are they to say? But a fight isn't a matter of opinion, it is too real.
Same with sex. "Listen baby, I'm a great lover." Well, we'll know in fifteen minutes. "Am I a real man?" The response stands.
The anxiety over a fight when your date is right there is that she will find out the truth about your masculinity. You'll take verbal humiliation over a beat down not because it hurts less but because (you think) it lets the question "am I a man?" rest unanswered. Plausible deniability.

IV.
Louis CK went for the dichotomy between what a woman wants intellectually and primally; that even though women may be anti-violence (e.g. Megan Fox) they still feel drawn to dominant men. But Louie got the subtlety wrong. A woman doesn't want the best fighter, she just doesn't want a man who won't stand up for himself.
What would happen if he lost the fight to the 17yo? Would she leave him for the 17yo? Cheat on him with a tough guy some Saturday night? (The cuckold problem.) "I just don't want her to think I'm less of a man."
Listen to the language: "I don't want her to think..." That's the infection of narcissism in the thinking.   Don't you think she has her own perspective? Don't you think that she already knows whether you are tough or not? Unless you have a secret identity, she already knows who would win the fight. Do you think you can fool her with words?
If she is a reasonably attractive woman-- defined as not bathing in smallpox-- then all that she gets, all day, is practice appraising men and filtering through their words.
She already knows who you are. That's why she is, or is not, with you, despite your attempts to convince her you are someone else. Losing a fight won't drive her to another man because if it would, she'd already be gone.

V.
The cuckold fantasy is when the girl cheats on her man with better, stronger, more masculine men. The cuckold problem is this: the cuckold fantasy is a male fantasy.
VI.
The question no one ever asks is: how did the 17 year old know he could pick on you? Why do you think he can sense something that your girlfriend can't? Feminist response: "See? Men don't think women can have their own opinions." No, we're not sexist, we're narcissists: it's not about you, it's about us. Men believe they can convince people of their identity-- convince a girl to like them. The whole male grammar is structured like this: get her into bed; get her to go out with me; show her what kind of a person I am. We think we can fool women for the same reason a 3 year old thinks he can manipulate his parents: sometimes they let us because they were going to do it anyway.

You think you can convince her you're tougher than you are, but you worry you can't fool another guy because he "knows" toughness. But why would he know it any better than she?   She knows you better than he does; and she knows men-- and posturing and puffing up the chest-- better than either of you. The only person who doesn't know what kind of a person you are is you.

VII.
Disagree if you want, but there's one thing that's indisputable: this whole scenario reads differently if the kid were black. A 17 yo black teen comes up to your table, and it goes from being an ego battle to a felony in progress. You think Louie would have told 5 black teens to keep it down?

Universal agreement: no one would think any less of you for backing down from a 17 yo black teen than if you backed down from a grizzly bear. "Dude, a grizzly bear tried to eat me, so I just gave him my lunch!" The hell you say.
And if you fight-- even if you lose-- no one is going to say, "ha ha, you got beat by a kid!" because everyone knows a 17 year old black kid has the strength of ten men. It's in the Constitution.
You think the cops are going to arrest you for fighting a juvenile?
I'll even go a step further: it would be the exact same if it was a 17 year old black girl.
There's a sense that blacks are violently unpredictable, that's what TV told me, anyway. You know that white kid in the Louie clip isn't going to murder you with the same certainty that you know this black kid might murder you.
While we're at it, we can all agree this would be a completely different scenario if it was a white kid rolling up on a middle aged black man on a date; or a black kid vs. black adult. No matter how equal opportunity you think you are all of those are different. Black kid on white adult is crime/poverty; white kid on black adult is racism; and black on black is "one of those things, you don't get involved." Unless you're black, then you don't have much of a choice.
If you want to know why we see these things differently, check with The Atlantic, they have all the answers that George Bush stole from us to give to Katrina. My purpose in using these scenarios is to lead you to realize that "what would you do if...?" is an impossible question because a situation doesn't happen to you, you are the situation. Louie wasn't the random target, he was chosen. The kid didn't pick on the woman, right? Nor did he threaten an empty chair. In other words, "what would you do if a teen comes up on you?" was already answered by the teen on the way to coming up on you: nothing. There's a chance he could be wrong. But probably not.

VIII.
Go back to Louie. Where did the whole thing go wrong?
An observation about the middle class: they have it deep inside their psyche that though they are taught to make prejudicial judgments based on hearsay, they are not allowed to show that they made them. The middle class think they are lawyers.
That kid was up to no good. You knew it as he walked to Louie's table, even before he opened his mouth. You knew it. But Louie/we were constructed to act only on what happens, not what you think is happening. Since the kid was polite, Louie had to be polite back, even though the kid was obviously being a bully-- you're not allowed to respond to that. "Hey, I was just being friendly!" And prove he wasn't. The kid offers to shake Louie's hand, "Hi, I'm Sean," and Louie has to shake it because so far the kid is being polite.   We relate things to our future cross examination: "isn't it true, sir, that sticks and stones can break your bones but names can never harm you?"
Since we're already knee deep in race: back when I lived in various bars in NYC, I frequently saw what I assume to be intelligent people allow what I assume to be dangerous black males come up to them at 2 am and ask them if they knew "the way to get to 44th St." Just for my Danish and German readers who generously donate, here's a geography lesson: Manhattan is a grid, in numerical order. Asking a New Yorker which way is 44th St. is like asking a Florida orange farmer which way is sky. But these white devils were willing to put their lives at risk-- not because they didn't want to appear racist, I saw the same hypnotized compliance when the perp was a white guy-- but because they are amateur lawyers: "he didn't do anything bad to me first." So we follow the script: guy asks for directions= "ten blocks up make a left." Guy pulls a gun= "look, I have 50 bucks, just don't hurt me."

do you mind drawing it on a map?

IX.
The Bully Dialogue-- where they spend ten minutes chatting nicely even though both of you know you're eventually going to get stuffed in a locker-- is another Cognitive Kill Switch, which is about reversing power and dominance.   The aggressive "Hi, what's your name, that's a nice shirt you got there" works because you're not willing-- you feel you're not allowed-- to respond to the situation for what it is: a bully trying to dominate the conversation. You feel obligated to reply to their words, and not the meaning. So the bully gets to bully the conversation for ten minutes, after which point it hardly matters whether you get stuffed in a locker or not.
There's a model for everything in childhood. In this case it's when the parent, rather than a direct confrontation (i.e. teach the kid how to be a man) tries to lead and trap the kid, like a jealous woman trying to catch her man in a lie. "So, Tommy, how was school?   Anything interesting happen today?" At this moment everyone knows it's a trap. Dad knows what happened, and Tommy knows what happened, and now Tommy knows that Dad knows, but Tommy still has to say, "oh, nothing really, " all the while thinking, "oh, great, I got to play this nutty game now? When I turn 18 I am so outta here."

X.
Back to Louie. When that kid appeared at his table, everyone knew why he was there. So this is how the scene should have gone, though I'll admit it wouldn't have been theatric enough for TV:

"Hi, my name's Sean, what's your name?"
"Get your punk-ass away from me, I don't want to know you."
Now the kid's either going to fight you, or back down-- which is the same thing that was going to happen anyway, but at least you stood up for yourself. She noticed.

---

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===== ====== ===== The Last Psychiatrist: Where Are They Now?
From April 3, 2008:

how the mighty have fallen...

...sideways

Cinco de Mayo is coming. It is inevitable.

===== ====== ===== The Last Psychiatrist: Where Did The Title Come From?

I'm sure you've read The Catcher In The Rye. Why is it called that?

And a few more that came to mind.

The Catcher In The Rye

Here's a little self-test for narcissism:

if you think Holden Caulfield "gets it" and sees through people's pretenses, you're a narcissist. Unless you are under 25, in which case you are completely normal.
if you think Holden Caulfield is really just sad and alienated, but afraid to take the dangerous steps towards adulthood and meaningful connections with other people, then you are perceptive; unless you are under 25, in which case you are a perceptive girl.

"You know that song, 'if a body catch a body comin' through the rye?' I'd like to be--"

"It's 'if a body meet a body comin' through the rye!' " old Phoebe said. "It's a poem. By Robert Burns."

"...Anyway, I keep picturing all these kids playing some game in this big field of rye....and nobody's around-- nobody big, that is-- except me. And I'm standing on the edge of some crazy cliff. And what I have to do, I have to catch everybody if they start to go over the cliff...I'd just be the catcher in the rye and all. I know it's crazy, but that's the only thing I'd really like to be."

Robert Burns also gave us Auld Lang Syne, which I have never once attempted to sing sober. Partly a metaphor for how Holden Caulfield sees adulthood (the cliff) and saving kids from it; but also an escape from any responsibility towards progress. He doesn't have to grow, or help kids grow, all he has to do is just be a little older and smarter. That's enough.

His absorption with phoniness is the inner conflict of one who is discovering that the world doesn't bend to his wishes.

Narcissism is normal in 17 year old boys, especially the quasi-idealistic kind embodied by Holden. They eventually grow up.   Hopefully, they then can remember what it was like so they don't destroy their kids when they're 17.

One day, a 17 year old will look at you and think you're a phony. That will mean either you are old, and he's wrong; or you're old, and he's right.

Atlas Shrugged

The book that was once dismissed as high school level sophistry has suddenly become the second most prescient book in modern history. The first is 1984. (#3 is Debt Of Honor.)

"If you saw Atlas, the giant who holds the world on his shoulders, if you saw that he stood, blood running down his chest, his knees buckling, his arms trembling but still trying to hold the world aloft with the last of his strength, and the greater the effort the heavier the world bore down upon his shoulders--what would you tell him to do?"

"I...don't know. What...could he do? What would you tell him?"

"To shrug."

Originally entitled The Strike, the book describes a future dictatorship where the dictators have created an artificial altruism: the productive are required to sacrifice themselves for others-- i.e. their output is taken from them and redistributed. The book describes this altruism as a trick; the society has convinced people that "it's the right thing to do," that it is just. It is a moral code and thus the productive members are coerced by guilt.

It could occur to Atlas that just because he is the strongest, it doesn't have to be his lot to hold up the world. He could simply shrug it off.

NB: such state control through a moral code would not have been possible if the productive people were narcissists (as our current crop of Wall Streeters seem to have been)-- they don't feel guilt. Only shame would have worked. The government might want to consider psychology before it sets up the next round of oversight.

Notes from the Underground

Quick test: give this book to your girlfriend. If she says, "it kind of sounds like you" then you're both in trouble.

There in its nasty, stinking, underground home our insulted, crushed and ridiculed mouse promptly becomes absorbed in old, malignant and, above all, everlasting spite.

A man who imagines himself an acutely conscious mouse, in a world of men who never bother with self-reflection, who seem all the happier, more capable because of it.

And he'll think about these happy, stupid men, and all the misery that their happiness has caused him:

For forty years together it will remember its injury down to the smallest, most ignominious details, and every time will add, of itself, details still more ignominious, spitefully teasing and tormenting itself with its own imagination. It will itself be ashamed of its imaginings, but yet it will recall it all, it will go over and over every detail, it will invent unheard of things against itself, pretending that those things might happen, and will forgive nothing.
But why do it to yourself? Why stay underground and... fester in spite?

But it is just in that cold, abominable half despair... in that hell of unsatisfied desires turned inward... that the savour of that strange enjoyment of which I have spoken lies.

Enjoyment? Better to consider it validation: in the suffering, in being the mouse, in being Underground is an identity, an individualism, a defining of the problem as you vs. them. You are not-them, and so you are better.

This is narcissism; sometimes despair is the only pleasure you have.

The lesser read Part 2 describes his relationship with a prostitute. He more than insults her; like a psychic he astutely identifies her inner dreams and external hardships, and then predicts the misery that is her future. He later says he did it to have power over her, which is only partly true. He does it because he wants her to see him as knowing. The power over her was to get her to see him the way he wanted to be seen.

But she has a good soul, she's a woman, and she's a prostitute: she's three times more perceptive than he is. He knows she'll eventually be able to see right through him-- to see him as he really is-- not even as a bad person, just not as he wants to be seen. This is the worst thing that can happen. To preempt this, he degrades her: to cause her to leave.

And of course, she does.

One of the best depictions of narcissism, ever. Study it.

The Sound And The Fury

Wherefore was that cry?
Seyton:. The queen, my lord, is dead.
Macbeth: She should have died hereafter;
There would have been a time for such a word.
To-morrow, and to-morrow, and to-morrow,
Creeps in this petty pace from day to day,
To the last syllable of recorded time;
And all our yesterdays have lighted fools
The way to dusty death. Out, out, brief candle!
Life's but a walking shadow, a poor player
That struts and frets his hour upon the stage,
And then is heard no more; it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing.

Macbeth, Act V, Scene V

Life is absurd; time is an abstraction humanity applies to it to help make sense of it, but it's artificial nonetheless. Quentin Compson goes to his suicide, Sartre once observed, not by passing through the present, but rather looking backwards, in retrospect, as if he is remembering his suicide in the past. Make plans if you want; your death came already. Six more thousand years of future people won't know or care about you.

A more modern interpretation, from the movie that ended a century:

Agent Smith has Neo ("Mr. Anderson") in a chokehold on the train tracks; the subway speeds towards them. Agent Smith is-- satisfied.

Hear that, Mr. Anderson? That is the sound of inevitability. It is the sound of your death. Good bye, Mr. Anderson.

Agent Smith has it figured right: Anderson's life, like all humans', was a pointless struggle even if it was a happy and successful one. It always ends in failure, in death.

Faced with the absurdity and unintelligibility of life, but the inevitability of its end; lacking God or country or dynasty, there is only one answer that today's man-- the narcissist-- can give that makes his life meaningful, and he gives it:

My name is Neo.

The only solace is to define oneself, otherwise you become aware that your brief life is all just sound and fury, signifying nothing.

One Flew Over The Cuckoo's Nest

three geese inna flock, one flew east, one flew west, one flew over the cuckoo's nest... O-U-T spells out, goose swoops down and plucks you out.

Which (I think) comes from the Louis Untermeyer poem "Rainbow In The Sky" which begins, "Wire, briar, linder-lock..."

A story (that can be) as much about racism and the Soviet Union as it was about psychiatry, many of these themes are underdeveloped in the movie.

The story's narrator is the Chief, whose grandmother used to sing the above nursery rhyme.
The Chief knows that the outside world is controlled by the Combine, and Big Nurse Ratched is its inside agent. Patient Randle McMurphy is her nemesis (or she his)-- she is control, he is freedom; she is conformity, he is a cowboy individualist who must become a self-sacrificing hero. He rips her uniform, exposing her breasts-- look, she's not a machine, she's just a person-- and he gets lobotomized.

Though it must be said: even a harsh, controlling, artificial world, like the Matrix or any good conspiracy theory, provides comfort because it says what every free floating individual wants to hear: you're powerless because someone else is controlling everything. But at least someone else is controlling everything.

The Last Psychiatrist

...the time of the most despicable man is coming, the man who is not able to despise himself....

---------------------------
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===== ====== ===== The Last Psychiatrist: Where Does A Tree Get Its Mass?
Whatever you just said, it's wrong.

A tree starts out as a seed. Where does it get the mass?

The common answer is: from the soil, which is wrong.

The mass of the tree comes from the wood (cellulose), and cellulose (by weight) is carbon. Carbon comes from the air (CO2).

I.

The first question you want to ask, right now, is why this now obvious answer wasn't obvious to begin with. More specifically, why you know the word "photosynthesis" but not how to apply it, at all.

Why were we taught photosynthesis? First, most of us don't remember anything about it anyway. If we do, we have recollections of certain unconnected concepts:

sun gives "energy"
plants "take up" "sunlight"
they "breathe" CO2 and "release" O2
It's good to talk to plants

The quotes serve to suggest we don't even really know the meaning of the terms we learned.

None of those statements are informative, nor can the be applied to reality (e.g. answering the above question.) It's not that you forgot; it's unlikely you could have answered that question even back when you were learning photosynthesis.

Yet-- and this is the point-- the word "photosynthesis" is in your head. You learned a made up word, an artificial carve out of what is really a fluid physical process. You didn't learn any of the reality.

So, on the one hand, we actually didn't learn anything. And, on the other hand-- the worse hand-- we actually think we know something. Not just ignorant; but ignorant and deluded.

II.

But "tree mass comes from the air" isn't actually right, either. Some trees are more than 50% water by mass, so the mass of a tree would indeed come from the ground. (No partial credit: if you said "from the ground" but were thinking "minerals" you were still wrong.)

Indeed, this question reveals that even with a general background in science, and two acceptable answers, most people still get it wrong. So what, exactly, was the point of the general background in science, let alone photosynthesis?

In other words, you don't really appreciate that a) a tree has water mass; b) air has mass.

I state it here, and you "know" it, but that's not the same as it being a fundamental part of your worldview, the way "the sun is hot" or "the earth revolves around the sun" does, fundamentals that allow you to make guesses about reality. That's what science should have given you; instead, it gave you a hodgepodge of disconnected linguistic propositions that neither describe reality nor predict reality.

"Where do plants get their energy?" "Photosynthesis." Nothing happened there, except words.

Here's an example: if, prior to this post, I had asked why a helium balloon, despite weighing something, floats, you'd have to reason out an answer. But just my saying, "air has mass" makes the question easier to answer. You already know air has mass, you don't need me to tell you; but you don't feel it-- that's why my telling you here makes a difference.

I hardly need point out how a discussion about global warming is vastly altered if it is intuitively understood that trees get their carbon from the air.

III.

But, actually, both of those answers are wrong: the question itself is meaningless. It is too vague, allows for multiple different interpretations and answers, is simultaneously misleading and oversimplified.

The bigger problem-- and this applies not only to science but to any field furthered by a dialectic-- is that we demand precision in answers, and allow-- expect-- imprecision in the questions.

"Where does the dry mass of a tree come from?" would be a little better. Etc. But no one worries about this; indeed, many shrug their shoulders, "yeah, the question is vague, but we all know what it means." Well, evidently not.

It barely requires exposition that psychiatry suffers greatly from this problem, the haziest and laziest of terms and definitions magically generating concrete and specific responses. Internist asks me, "I have a patient who is bipolar, what should I do?"   If I say anything other than "Depakote" or equivalent, he thinks I'm being an ass. But my answer is 100x less relevant than understanding what he means by either "bipolar," "patient," or "do."

Politics, I need not point out, is worse. The most asinine questions are expected to generate meaningful responses. "Should we bail out General Motors?" Which one of those words actually means what you say it means? Who is "we?" What's a "bail out?" "General Motors" the whole company, the pension division, the new plant they opened in Russia, what? But if you ask for any clarification, you're being difficult. You don't get it.

IV.

A final analogy may be here helpful. You may also (not) remember from school "significant digits."    For example, 3 + 4.2 = 7. Since "3" only has one significant digit (3.0 is a more precise number with 2 significant digits) the answer itself can have no more than one significant figure. Importantly, it's not that "7" is an okay answer, but really 7.2 is more precise. 7.2 is wrong, because that 3 could have been 3.4, 2.6, etc.

Or, more generally, an answer cannot be more precise than its data. Or its question.

The first business of science education should not be to help us answer questions, but to help us ask questions.

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===== ====== ===== The Last Psychiatrist: Where Parents Go Wrong

it's not genetics, it's repetition compulsion

This is the story told to me.

A 38 year old woman, Anne, married with three kids, has a 17 year old brother, Tim, who still lives at home with his (and Anne's) parents. Tim got his teenaged girlfriend pregnant. Oops. Should he have an abortion?

While he felt he could tell this to his big sister, he definitely did not want to tell his parents. They were crazy-- a fact corroborated by Anne. They weren't just strict, they were almost delusional. Denial, avoidance, displacement were the main coping styles; do nothing was core policy. Bill too big? Procrastinate. Coughing up blood? Humidifier. There was plenty of affect there, especially anger, but it was always focused on arguing about the problem, never solving the problem. "All those stupid doctors will do is charge my insurance thousands of dollars and then say they don't know anything. Crooks, crooks I tell you!"

The first panicked phone call Anne received was the day Tim learned his girlfriend was pregnant. "I don't understand this! I used a condom every single time! I'll bet she was cheating on me!"

A few days later he became a political philosopher. "You know, these Glen Beck freaks want to control what a woman does with her body!" And it became cleverly self-serving: "Men don't have the right to tell a woman what to do. It's ultimately a woman's decision, right?"

For two weeks, the teens were individually and collectively on the phone with Anne and her husband trying to make sense of their own conflicted emotions.

Of course, Anne and her husband were highly conflicted as well. Wrestling with the reality of an abortion, or not, and that they had been sworn to secrecy. They couldn't tell the parents. Everyone was in full agreement that the irrationality of the parents would make any decision at all nearly impossible. The teens would eventually have the child not because they chose to, but because of paralysis.

II.

Not a spoiler: Anne has to get on the phone right now and call her brother and say the following words: "if you don't tell mom and dad in the next hour, I will." And hang up.

Why in the next hour? Because idle time leads to catastrophes, like suicide. He should not be given any time to "realize" that "there's no way out of this."

Anne's job is not to protect Tim from their insane father. If Anne wants to be supportive, she can say, "I'll come with you to tell them, and I'll help calm the Unabomber down."

By not telling, Anne sets herself up to be hated by both the parents and her brother. The parents will, of course, say, "how could you not tell us? He's our son, he's a minor! How would you feel if this was your kid!?"

In ten years, her brother will get to say, "you know, that was the hardest decision I ever made, and I wasn't really mature enough to make it, and by not telling, you let me make it alone. Basically, if it hadn't been for you, I would never have gotten an abortion."

III.

Tim understandably didn't want to tell his parents. But instead of owning his decision and not telling anyone, he brought his sister and husband into it. Why?

The therapy answer is, "he wanted some support." But really, he wanted to unload a heavy secret, discharge the energy. He wanted to get to the "I feel better just talking about it" stage. The shame part had been overcome. Now he was free to decide what he wanted to do.

This is why he chose to tell his adult sister. It wasn't because he valued her advice and wisdom. He told her because she was an adult, a parent of three kids. That's the next best thing to telling your own parents. And so if Anne was ok with not telling her parents, then for sure he could be okay with it. Adult decisions, made by an adult.

Of course, by unloading, he had loaded her up. He didn't care about that. Instead of him being up all night thinking, "oh God, what have I done?" he was sleeping. Free of morality and ethics and shame and guilt, he could focus on logistics. She was the one up all night, "oh God, how did this happen? What should he do? What should I do?"

In short, Tim had chosen the worst possible posture: passive-aggressive. He didn't take his burden on his own shoulders, like a man, and not drag anyone down with him; nor did he assert himself, again like a man, and tell everyone what had happened and what he had decided, and take the consequences. No. He boldly asserted his autonomy on someone with no power over him and hid from the people who had a lot.

V.

"But what about Tim's girlfriend? Why doesn't she boldly assert her autonomy somewhere where it counts?"

Of course she should. Obviously, everything said here applies to her. But How To Be An Assertive (Not Aggressive) Woman was written in 1976. Women's trouble now isn't how to assert themselves, but picking from the overwhelming availability of choices.

But more importantly, it is a real problem for men (and consequently for women.) They aren't assertive, they only pretend to be assertive. That's why they think they look for manliness in fictitious characters that no 70 year old man would ever think was a real man. Don Draper, Tony Soprano, and pretty much any rapper are to men today what Mary Tyler Moore was to women in the Pleiocene epoch. Note carefully the relationships of all of the above.

Even if passive-aggressiveness is stereotypically ascribed to women, it is always considered in contrast to directness of men. The two offset each other. If you follow this logic, then passive-aggressiveness in men is a disaster.

VI.

I'll grant you that this thinking is not abnormal or pathological in a 17 year old. But this is a pivotal moment. How he deals with this-- one of the hardest decisions he will ever make-- will set the stage for how he deals with all future lesser calamities. If passive-aggressive works for a pregnancy, it's for sure going to be the default for tardiness and infidelity.

His parents are probably going to say, "we didn't raise him right! How did he not learn that abortion is wrong?! Why didn't he listen to us all these years?!"

In fact, they raised him with total precision. They made another one of themselves in every way. He learned how to deal with problems from them. He learned what's right and wrong from them-- and what he learned was that the reason abortion is wrong isn't because it is wrong, but because they say it's wrong;  that what's right and wrong is determined not by an external ideal, but by whoever in the room has the most power. I hope you all know by now how this all turns out.

----

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===== ====== ===== The Last Psychiatrist: Which Is Healthier: A Dunkin Donuts Bagel, Muffin, or Donut?

too bad the prices aren't also variable

Bagels:

Dunkin Donuts has a "DDSmart" menu, which means it's healthier. That should be obvious.

Except that there is nothing about the multigraining which makes it healthier. It has more calories and more fat (due to the oil they need to add to make it soft). They say "reduced fat cream cheese" only adds 100 cal and half the fat (8g) but that's if the cheese is spread by a bee.

Donuts:

Three points:

No worse than the bagels. More fat, less carbs... you decide.
Anything labeled "cake" or "crumb" should be avoided like the clap. And if it claims to have a fruit in it, get tested for gonorrhea as well. The apple/blueberry crumb has 470 calories, none of which are delicious.
Most of the other donuts (cruller, frosteds, jelly, pudding kremes (boston, bavarian, etc)-- are all about 250 calories.

Munchkins:

Munchkins all look like this:

i.e. they are identical in proportions to their adult counterparts. So know thyself: which is more psychologically satisfying, one donut or 5 munchkins?

Muffins:

Muffins are the Matrix's punishment for our arrogance, believing we can make birthday party cupcakes healthier simply by making them larger and renaming them.

On the positive side, as of October 15, 2007, all DD products were trans fat free.

Cookies:

What I'm about to show you is not suitable for pregnant women or patients recovering from surgery.

Here are the stats on the Triple Chocolate Chunk Cookie, as told by DD (orange and white) and an independent site called Calorie Count:

If you add up the fat, carbs, and protein, the DD stats equal 72g, and the Calorie Count stats add to 110g. The actual cookie I bought today weighs 140g. So is Dunkin Donuts telling me that the other half of the cookie is water and oxygen?

So I'm going to bake this cookie until it becomes a cracker. Check back tomorrow for the results of the cookie analysis.

--

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Which Is Worse: An Altered Photo of Reality, Or A Photo That Alters Reality?

On the left is real 1989 Tiananmen Square. On the right, a doctored photo. 300 people were shown either a real or altered photo of two different protests, and then asked to recall what happened back then. The point of this study was to show that altering a photograph will change how the events are actually remembered (in this case, as bigger and more violent.) It's important to emphasize that the subjects already had a memory of the events (from TV, etc)-- so this photo actually changed their pre-existing memories, and they weren't aware of it.

But, here's the thing: these subjects weren't actually at the original protests. Their original memories also came from images-- hopefully not altered images, but certainly selected images. Right? The TV newspeople didn't pick the boring pictures, did they? I get that doctored photos are bad. But how much of our memories and knowledge of the past are largely determined not by "reality" but what, or how, we were shown it in the first place. Obviously, a lot. Therein lies the question: is it worse to see a doctored photo, or doctored reality?

Here's an example: search your mind for recollections about the Tiananmen "episode" in 1989. Can you remember anything-- anything at all-- other than that guy standing in front of the tanks? Do you remember who was protesting? Why? The question isn't why you don't remember anything, hell, it was 20 years ago and a solar system away; the question is why you do remember that guy. Are you better off for knowing this? Are you smarter? Or do you carry the false impression that you know something about which you really know nothing? That's the Matrix-- not only do you have false memories, but you get to feel good about being a knowledgeable, aware, citizen of the world.

NPR runs a cult this way. It offers an eclectic mix of topics, selected on purpose to allow you to think you are getting depth. You listen to NPR, and you think you're learning, growing, becoming a Renaissance Man. You're not. Sure, it beats CNN, but that's not a battle anyone is supposed to lose. Its target audience is insecurely intelligent people who want desperately to be intellectual and well read but who don't actually want to read too much. What NPR offers is sentiment; the feeling that you know something. That's why when someone asks you a question about a topic you learned about from NPR, you inevitably answer using the same language and words NPR used. Do you understand? Back during the election, I'd bet people at the bar that I could tell them the reasons, using the exact same words, why they'd vote for their candidate.

This speaks to psychiatry, of course-- and politics, and economics... when so few bother to read primary sources, instead relying on "experts" to tell us what was in the primary sources, is altered data really going to matter? I'm not for changing reality, but when you can spin a story any way you want regardless of the truth, and no one will bother to check it, what difference do facts make?

Think about this: no one would know you altered a photo or data in a primary source article, because no one would ever actually see it. They'd only hear about it. (Same with references.)

---

But wait, there's more.

The two news articles aptly summarize the study, but why did they bother to summarize this study? Well, the message was pretty important to journalists: "doctoring of photos is bad, you bad journalists who do it."

The best line comes at the end of the one story:

"[Doctoring photos is] potentially a form of human engineering that could be applied to us against our knowledge and against our wishes, and we ought to be vigilant about it," said UC Irvine psychologist Elizabeth Loftus, who designed the study. "...as a society we have to figure how we can regulate this."

Regulate? What, the use of doctored photos in the media, which is actually already regulated? Or the doctoring of photos anywhere-- maybe a disclaimer? An automatic Photoshop watermark that says "This photo altered reality with techniques other than staging, lighting, cropping, deletion of undesired photos of this event, the placing in proximity to or away from other photos, and does not fit in with the currently acceptable social narrative as determined by your betters?"

Sorry, I'm wrong; the best line comes at the end of the other news story about this study:

"Any media that employ digitally doctored photographs will have a stronger effect than merely influencing our opinion -- by tampering with our malleable memory, they may ultimately change the way we recall history," says lead author Dario Sacchi.

Really? Only the ones that use doctored photos?

Really? Change the way we recall history-- the old way of being told what happened was so much better?

------------

A man can walk away from a news story like this and feel like they understood the point. He can then pat himself on the back if they go look up the actual study and confirm the point.

But it's not enough. What's the context?

You say: "whaddya mean context? It's science, it's the pursuit of truth." Well, ok, you should go back to NPR.

Part of the problem with reading articles on line is that you don't get to see the other articles in the issue, which together tell a story.

The study appears in Applied Cognitive Psychology. In the same issue appears a well thought out article about how the media influence the "public narrative;" another study called, "Photographs Can Distort Memory For The News" in which they find that a (real) photograph accompanying a news article will add memories the subject thought came from the story; and a tie-in essay that concludes, "Taken together, the papers in this special section show how the media can shape what we believe, what we know, and what we remember."

Do you see? You have a set of facts that can be manipulated endlessly to tell any story you want. Here, a journal issue about being wary of the awesome power of the media gets used by journalists to say watch out for Photoshop.

If it was malicious, you could punch someone, but it's not, that's the point: the authors of the news articles probably didn't even know what else was in that journal. They got partial information, and ran with it. And, of course, by printing it they thus validate it.

It's like James Joyce said, "we can never know the truth so long as we have ears and eyes." Actually, he didn't say that, but do you see how you paid attention?

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===== ====== ===== The Last Psychiatrist: White People Think Black People Are Dirty

obviously he brought the trash with him

In Science, a study about racial stereotyping. Science, as you know, is read by scientists, which means they are progressive intellectuals who never racially stereotype. They voted for Obama to prove it. Though they unanimously subscribe to Evolutionary Psychology Bible they themselves are not subject to evolutionary forces; but it is helpful and entertaining to learn what makes the animals in the red states do what they do.

When you're short on time and long on caffeine skip over the study itself and just look at the Introduction, where you will always find two things.

Unnecessary references:

There is substantial evidence that discrimination has serious negative consequences for those who are discriminated against, as well as for society in general (1-3). A neglected possible source of stereotyping and discrimination is physical disorder. The environment can affect the relative accessibility of important goals (4, 5), and recently it has been found that physical disorder in particular can, through shifting the relative accessibility of goals, increase littering, trespassing, and even stealing (6).

None of these sentences need referencing, because none of them contain a proposition worth referencing. They are either definitional (e.g. racial discrimination is negative) or uselessly vague. Yet we have exhausted 6 out of the 24 references to be told nothing.

Next: references that don't actually support the statements they are supposed to be supporting.

There is some evidence that stereotyping is goal-driven (7-9), and there is even evidence that when people's desire for structure and predictability is high, they are more likely to engage in stereotyping than when it is low (10-13).

Reference 10 is a review article about existentialism.
Reference 11 has the word stereotyping in it, but isn't about the link to predictability.
Reference 12 describes the kinds of responses that occur when expectations (not stereotypes) are/are not confirmed: "will this taste good?" "If you are told Paul is a kind man, how will you react when he isn't?")
Reference 13, is about how the goal of interpretation affects the interpretation/stereotyping.

I should also point out that all four of those references happen to have been written by the same person who wrote the sentence they were all supporting.

II.

For no reason I know, works of philosophy are compromised by even a typo in the introduction, but in science you can open with a golden shower anecdote and no one notices. Oh well. To the experiments.

The setting: a Dutch train station. 40 Caucasian men and women were asked to sit in a row of chairs and fill out a questionnaire about Muslim and gay stereotypes. Chair 1 was occupied by either a white or a black researcher, which they term a "confederate." Yes, like they're grifters. Where would the subjects choose to sit?

The experiment was run twice: once on a day when the station was clean (order condition), and another time a few days into a janitorial strike, i.e. in a dirty train station (disorder condition.) How did the disorder affect the choices white people make about where to sit?

We predicted that in a dirty train station people stereotype more and would choose to sit further away from an outgroup confederate than in a (relatively) clean train station.

Conclusions:

Importantly, this stronger stereotyping in the disorder condition was accompanied by a significant increase in the distance the respondents chose to put between themselves and the black confederate..

There are a number of reasons why this study is silly, but, unlike the researchers, subjects, and striking janitors I am not being paid for my nonsense, so I will only list a lot of them.

The subjects are completing a survey about Muslim and gay stereotypes, yet are sitting near a black man. Would the results have been the same if the confederate was gay? No? Then it's only measuring racial stereotyping, which is fine, but then you can't say this:

... In a disordered environment, people are more likely to distance themselves from outgroup members than in a clean and ordered environment.

Trust me on this: 'outgroup' has a whole different connotation in The Netherlands than in the U.S. But the sleight of hand is to take a white vs. black racial study and convert it to a scientific generalization about stereotyping, the kind where some other study can use it to say, "there is evidence to suggest that people distance themselves from outgroup members."

Would the results be the same if black subjects were studied? Perhaps this is a study of prejudice and fear, i.e. white people are afraid to sit near black people but black people are also afraid to sit near black people, which would produce the same graph. But you'd have to rewrite the conclusions because it wouldn't be about "outgroups."

Right about here I you want to take a drink, because apparently the only scientist in The Netherlands that has sex with strangers is me. Think about his study, and the results, and what you think it means. Now look at these photos:

Suddenly the seating choice takes on a different hue.   Is she avoiding the black man in the top picture, or is she looking to get penetrated in the second? BE HONEST LIARS. I will admit that technically the author remains correct, both interpretations are the result of "stereotyping," but one happens to be a negative stereotype and the other happens to be a substantial plot point of every drama on ABC. Here's a revised title for the study: "Clean Stations, Dirty Minds: How Just The Right Conditions Can Make A Woman Go Black. (But She'll Be Back.)"

The study assumes that how close whites sit to whites is the default, hence a black confederate in a dirty station makes them sit "further away"; but why isn't the distance they sit in the disordered condition the default per race, and other things make them close the gap? This is especially true if the subjects are used to disorder as the typical state of affairs, i.e. they're from Rotterdam. ZING! (It is, after all, a train station.)

If you want to go Schrodinger, remember that the subjects in both conditions are surrounded already by other white people who are observing them (the interviewers). They are not alone. In ordered environments, does this make people feel safe/horny/cold/social enough to move closer? (i.e. if the interviewers were not present, perhaps whites would choose to sit equally far from black people in both ordered and disordered environments. They'd still be racist, but things couldn't make them more racist, only less racist.)

Note also that the default condition for the station is clean; the janitorial strike caused an unusual circumstance. How would the results come out if the station was usually dirty and one day became unusually clean?

And etc. Instead, the study closes with this:

Thus, the message for policy-makers is clear: One way to fight unwanted stereotyping and discrimination is to diagnose environmental disorder early and to intervene immediately by cleaning up and creating physical order.

That's the kind of delicious "broken windows" soundbite that gets you published in Time Magazine, but why would the effects last more than a day? Wouldn't people become desensitized to the disorder?

I don't even doubt the conclusions, but you have the moral decency not to overlook the flaws just because they match your prejudices. This study does not logically lead to those conclusions, this study is sufficiently vague and flawed that no conclusions can be made, at all.

The reason this matters is because if the study is published in this way, with these conclusions, people will assume it is science. This becomes a "known." Next thing you know it's in a Malcolm Gladwell book and that's the game.

These points seem not to have occurred to the following people: the two authors of the study; the guy who took this photograph; the four peer reviewers; the editor; everyone who read the study.

I don't blame them, but as I am not the smartest guy in the universe it should have at least occurred to someone, and thus we have the fundamental problem of psychological research: it shouldn't be reviewed by peers. Not because they are stupid, but because they are in the same "world" and can't see things from the outside. It should be reviewed by physicists; but if it was, there'd be only one psychology journal left and it would be empty. I reviewed Justin Timberlake's In Time more closely than anyone reviewed this study.

Two things happen with studies like these: either they enter the Sea Of Publications, another meaningless ion of sodium that does nothing else at all except contribute to the rising sea levels that will eventually kill us all; or they get used by government policy guys to justify, well, it depends: justify making trains stations way cleaner, or way dirtier. Your city's needs may be different.

III.

So the study is an interesting observation about which no conclusions can be reached. However, there's a further punch line to this: the study was a fraud.

Diederik Stapel, noted Dutch psychologist, was recently outed for massive scientific fraud, i.e. he made up all his studies. "All of them?" Does it matter?

The scientific community is aghast at the extent of his fraud-- fraud on "Astonishing Scale", writes Gretchen Vogel in the same issue of Science; and Bruce Alberts was so furious he wrote an "Editorial Expression Of Concern." Ooooooooohhh. People's Elbow.

The battle cry now is that science has to be done differently in order to prevent fraud; but the important truth is that this study should never have been detected as a fraud because it should never have been published in the first place. The cacophony of self-righteousness among everyone with "professor" somewhere near their name is a diversion from the reality that the way the entire field conducts research and draws conclusions is suspect.

Hide behind Stapel, strap some Kevlar to his chest and let it draw fire while you deploy a few more studies to the journals that are of dubious quality and of no consequence, the system has to hold just until you make tenure. I know.    These studies are useless, worse, they are perfectly packaged for the media and popular consumption so that in spite of their meaninglessness they will change the way people think and change the way society acts. I wouldn't have used this study to win another drink in a bar argument but some minister somewhere will use it to demand 300M euros or whatever they will use next month for clean stations or racial purity.

IV.

"Why is Alone lenient on the judge who beats his daughter? Can he really believe Wall Street is blameless? He thinks the media is creating a straw man of a college kid angry at Paterno's firing?"

You don't need me to point out the obvious bad guys, there is no point for me to decry scientific misconduct and pedophilia. But when I don't do it you think there's something wrong with me, that I'm blind. Why do you want me to say the things you already know are true? Because that's what you were trained to want.

What you need me for is to untrain you, force you to realize that focusing on the obvious bad guys is a defense against looking at everything else, because that everything else is you. You were trained by media which labels hypocrisy as the worst sin imaginable; and individual instances of corruption-- hey, there's a welfare cheat, hey, there's Bernie Madoff-- as the appropriate target for your wrath. Bernie Madoff is not your problem, he is not your enemy, and unless you lost money to him he is nothing to you; and as long as you can be reminded to be angry at him you are not going to ask why the system needs Bernie Madoffs to survive. Stapel may have invented the data that no one will look at but Science didn't vet the conclusions that everyone will remember. Which is worse? "Keep your guns trained on the bullet proof straw man. Look over there, he's a jerk!"    If they can drive you to rage, they've succeeded.

Here's the synthesis: there's an argument against OccupyWallSt, and another about a beating your daughter, and another about raping some kid in a shower, and this, and etc-- all of these are the same thing. All of these represent the institutionalization, the mainstream acceptance, of self-serving behavior because that behavior allows everyone else to be equally self-serving. Or, in more basic yet precise language: individual narcissism is encouraged to permit the existence of societal narcissism, all of which is at the expense of your soul. Repent.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Who Are We?

A recent article in the New York Times, written by Richard Friedman, MD, is called Who Are We? Coming Of Age On Antidepressants.

The article can be summarized: "I've been on antidepressants for most of my life. How do I know who the real me is?"

It's an interesting question, and many have attempted to answer it. But the question is faulty, because it assumes there is a "you."

And, of course, there isn't.

A medication doesn't alter your core personality; your personality constantly changes, adapts, to stimuli. Why do some people go all Zimbardo at the drop of a hat, while men married of 20 years become infuriatingly repetitive in their behaviors?

It's no different than the antidepressant question, which is no different than anything else. You're confused because it's a medication, but there are other things more powerfully transformative than a pill. For example: divorce. You may think the "real you" married your wife or husband, but I am confident that if you had married someone else, you would have been a different person-- sometimes dramatically different. Example: a gazillion women who are in their second (happier) marriage have told me that they don't even recognize the woman that they were in the first marriage. "I can't believe the things I did-- in some ways, I was actually a bad person." And they describe being manipulated-- and manipulating; being selfish, etc. Circumstances made them "bad," and the healthier second marriage has made them into a healthier, better person.

Or whatever. I'm not saying all first marriages are bad, and you are bad for being in them-- I'm giving an example of how an external event that you chose drastically alters your identity. The pill is no different.

The reason so many people can't accept this existential position is because many parts of personality seem to remain consistent despite significant events, meds, etc. But much of the consistency has to do with consistencies in other environments. e.g. You had two marriages, but the same job; or you still saw your parents every weekend; etc, etc. Those anchors fix parts of your identity.

Friedman offers the example of a woman who has been taking Zoloft for 8 years, and has had a decreased libido.

She had understandably mistaken the side effect of the drug for her "normal" sexual desire and was shocked when I explained it: "And I thought it was just me!"

This is an exceptionally good example, because it shows why Friedman's logic is wrong. Why is it Zoloft's fault? How do you know she just doesn't have a low libido?

I know Zoloft has sexual side effects. But he jumps to the conclusion that because they have side effects, that must be why she has a low libido. But do sexual side effects happen in everyone? The package insert says 6-11%. I'll spot you 20 points. If 30% of patients have decreased libido, is it logical to blame her low libido on Zoloft, and not on anything else? She doesn't say she has a decreased libido; she says she has a low libido. See the difference?

But even that explanation is a distraction. Friedman misses the point altogether: she has a low libido. Period. Maybe it's the Zoloft, maybe it isn't, but unless she is coming off the Zoloft; unless she just started it that you are noticing a change from before; then the point is moot. Low libido is her identity. Perception isn't reality, behavior is reality.

What people want is there to be a core, perceived identity-- "I'm X"-- that can be pharmaceuticalized into existence without the requisite behavioral effort. "I should be happy." Well, actually, no. You shouldn't. You may want to be happy, but there shouldn't be an expectation of it.

If you are normally a happy person, and then become depressed, then you can say the meds are returning you to normal. But if you have always been depressed, and the meds have changed that, you are not returning to normal, you are moving further away from normal. I'm not going to judge this as good or bad-- I'm simply saying that you're not returning to core, you are different.

The key here is that early childhood if of huge importance in creating anchors, which will allow some consistency of personality throughout life.   Consequently, the extent to which you have some personal traits will determine how easily you change the others. e.g. narcissists can be relied upon to become violent even when they "are" not violent people.

But, ultimately, you get to choose who you are. Choose.

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===== ====== ===== The Last Psychiatrist: Who Can Know How Much Randi Zuckerberg Is Worth?

cue hatred

Part 1 here

IV.

Off topic: Randi strongly believes Facebook has a legitimate place in the business world, and this makes me think Facebook is finished. I realize this is a speculative trade to make. The usual anxiety about Facebook's future is that teenagers aren't interested in it, but the more relevant demo here is adult men, especially the ones in suits. Facebook runs 60/40 women to men. In the language of self-aggrandizing social media, that's a tipping point. 5% more estrogen and Facebook will be perceived as a women's site and no guy will want any part of it except for guys you will want no part of. Hush yourself, you have your sexism backwards: The instant a woman notices a man flipping through Facebook and one eyebrow goes up, you can head to your car and beat the stadium traffic, the game is as good as over. That's what happened to Myspace. It tipping pointed into "unemployed/some high school" and The Ruling Class had to sell it to Ima Holla Achoo for 20x less than they bought it. Now it looks like Windows Mobile, which is demographically appropriate.

Lose the men and you've lost Big Business, and at some size point a technology needs Big Business to want it, which makes Pinterest more valuable than Instagram and WhatsApp completely worthless. This is the story of Blackberry. The conventional wisdom is that people didn't like their emails in monochrome and preferred the sleek and sexy iphones, but you probably remember all the business casual salarymen proudly carrying around two phones like some bourgeois Frenchman with a dignified wife and a touch sensitive mistress, a couple years in a guy's going to get to thinking, "what am I, a Mormon, how did I end up with two wives?"   When Business was henpecked into supporting the iphone, Blackberry went sadly into menopause and defiantly into Africa. Plausible deniability requires that I do not explain how layered a joke that is.

V.

I want to believe that Randi Zuckerberg is delusional, that because she is so wealthy and famous she sincerely believes if you take a MacBook Pro to a Panera and start a mommy blog or a particle accelerator, follow your passion, you should be a TEDx speaker in no time, but don't forget it's hard work, money isn't everything, and take time out to unplug!

But this person was at Davos. Now I'm confused, was the invite Mark + 1? That's the easy criticism to make, that she's famous only because of her brother, but nepotism only gets you so far, Mark has a much more intelligent wife who just graduated medical school and no one is interested in her, and when the media has no other choice but to acknowledge her they do this:

I know, I know, it's probably photoshopped. Still.

So on the one hand the media has no idea what to do with an Asian physician except depict her as a borderline psychopath on Grey's Anatomy, on the other hand they are excited to interview a lunatic who broadcasts the appearance of excessive action-- frantic activity as a defense against impotence-- that's what the demo wants, and if you've been paying attention you will understand the translation: since the target demo has no idea what to learn from the experience of an Asian woman who despite marrying the Powerball became a physician anyway, you get Davos updates from a woman who plurals adjectives. This isn't a criticism of her, it's a criticism of you: what do you expect to gain from all the haste, the energy, the "finding ways to be creative?" Unlocking creativity is the third biggest swindle perpetrated by managment consultants, after open floor plans and managment consulting. Creativity was never the problem, the problem was always the math.

Randi probably read her book herself and I don't doubt that it took months to come up with the phrase "dot complicated", after which she needed a vacation, but she doesn't understand why she wrote the words she did, what forces were acting on her, and what these forces wanted from her that she was elevated to celebrity status. Consequently, her demo doesn't understand either: they think she's an idiot. This woman went to the World Economic Forum, which you probably think is irrelevant and you'd be right, but grant that they are at least pretending they are relevant; yet they still allowed her in, knowing full well if anyone found out it could completely obliterate their legitimacy. Why take such a gamble, to what possible benefit? Look, if Scarlett Johansson is going then at least you can say Scarlett Johansson is coming, I totally get it, but putting Randi Zuckerberg on the brochure should be brand annihilation.

for the sake of this premise, pretend she came to the 2014 Davos

"I'm pretty sure that's Charlize Theron, not Scarlett Johansson." And I'm pretty sure they're the same person, and just because now she's Rachel Maddow doesn't mean she's serious. "But she did actually do serious humanitarian work." Yes, great, how about that. Is there a blonder picture we can use for the flier?

It's probably very frustrating for whoever that woman is to try being anything other than whatever she is because no one will see her as anything but that, but this is the nature of the trade off: you spend your life trying to be seen as something, then if you happen to succeed then you will not want to be only that anymore, you are really something else. But the world and/or your girlfriend won't listen. This is especially hard if you simply age out of it, you want to move on with new ideas but the jerk in the supermarket wants you to be the person from '99, which means that the jerk in the supermarket still is the person from '99 and can't understand how calendars work. "You changed!" he hisses with disgust because you fail to normalize his cortical sclerosis. Sigh. You can't punch him, there are witnesses. There are always witnesses, and they will all be from '99.

VI.

You would be forgiven for thinking Randi was at Davos merely because she's rich, but consider that Warren Buffett was not there. He's a capitalist, not a globalizer, so his brand doesn't synergize, in fact, he is the competition. "No, he knows Davos is irrelevant!" So why does he go on CNBC? Buffett is a CNBC favorite, but what's so remarkable about his appearances is that while he is branded as a sober "buy and hold" investor, he is only ever asked about short term trends: are we at a bottom, what will the Fed do tomorrow, etc. Why? You know what he's going to say: "You want to buy good companies when they're undervalued," he'll intone over a cheeseburger, callously unaware that there are only 7 minutes until the close. --What about Facebook?! Buy at 57?!   "Oh, I don't know anything about those new fangled tech stocks, I liked Wrigley's as a child, I understand the company, it offers durable competitive advantage." --Oh, Uncle Warren, you're so out of touch! (But the rest of you understand Facebook, you liked it as a child, doesn't it offer competitive advantage...?)

What does Watch Us With The Sound Down And Feel Like You're Active need him for? It's not his words, it's him, he's the draw, he is the aspirational image of the demo of 35-54yo hopefuls: "Someday I'll be old, but when I am, I'll have become rich through the market." So keep trading.

And here I have to go back over something. The harder part of the psychology is that the demo doesn't want to become full time traders, either at home all day or on Wall Street-- that part must remain a fantasy-- because then it would be a job and it wouldn't count; it has to be a side gig, then their success wasn't their "work self" but their "real" self; no one else can claim a sliver of that success-- not the liberals with their "'entrepreneurs' just pretend they don't benefit from public services!" or the wives with their "behind every good man...!" or the echoes of their father yelling, "you need to apply to Sperry Rand, now there's a company you can put in forty years with!" It all happened in their head, no one else can share the credit, it is 100% a consequence of their personal value.    Bonus: if they fail, it can be quickly discounted as merely a hobby-- that wasn't, after all, their real self.

The mistake is in thinking this has anything to do with the money. It's said that most at home traders fail, but this is incorrect: they fail at making money, but they are successful at feeling like a trader. That is the goal; the money is secondary, which is why they fail at making it. The buy/hold/reinvest the dividends strategy of Buffet is totally opposite to what's desired, because the strategy does not involve market timing or status updates, it is on autopilot, and there's no "i" in autopilot. Well, there's one, but it doesn't stand out.

The trading activity itself-- the frantic activity-- keeps the rest of reality away. You're not your job-- you're something else. You're not your family, you're more than that. Things have the potential of possibly happening someday, and no work will have been necessary to accomplish it. Just you wait.

But even that's not true. The hardest part of the psychology is that feeling like a trader isn't the final goal. Turn CNBC back on, there's Buffett, and oh, look, there's Peter Schiff. Peter Schiff is another CNBC favorite, and his presence is even more incongruous until you understand it isn't.   Whatever your opinion of his opinions-- debt/inflation/government/armageddon-- his are more political than financial or macroeconomic rather than technical and anyway they are 100% long term opinions. He may tell you to buy gold for the coming collapse, but you have a few years to open a position. So why is he there? "Because he's right!" No-- why is he on Fast Money?

Here is the unspoken fantasy that explains the presence of Warren Buffett and Peter Schiff on CNBC: "Someday I'll be old, but when I am, I'll have become rich through the market. And then people will want to interview me."

VII.

Swap out the demo, and this is Randi Zuckerberg. She believes she is worth all her money, she believes she is more than Mark's sister, she believes she has valuable opinions. Anyone who disagrees is a hater. You're just jealous. "No, she's a fool!" Then how come she's so rich?

Those who are enraged by her are actually suffering from the same delusion she is, which is why her target demo as seen by Davos includes her haters. The standard criticism of her is that she didn't really do anything to deserve her money-- "she got rich because of her brother"-- but this is a profound disavowal of the reality: she got rich because of timing-- even though her job at Facebook was trivial, she was there from the beginning and got paid in stock options. What's interesting is that no one makes this criticism of her, because that's what her haters believe is supposed to happen to them.   She timed the market the way you're supposed to; what she did that makes her hatable, therefore, is that she had inside information.

I don't begrudge anyone the good fortune of right place/right time, take your money and run, but first drop a knee and be humbled before God reflecting soberly on the knowledge that you didn't deserve it.   I love getting paid, do whatever you can do to get paid, but do not let the money whisper to you that you are worth it, it will be lying and you will believe it. You hold a fetish of value and not actual value.   But even her haters want the money to mean retroactively they were already deserving of it, this kind of fortune has bypassed reality testing and instead creates a new reality, it uses the truth in order to lie: of course I'm not rich because of my work product, duh, you can't measure a human being's value based on his labor. I'm rich because that's what I'm worth. "Isn't that specious reasoning?" Oh, dear, sweet, earnest, Lisa, I want to buy your rock.

And so the hatred of her, like all hate, is revealed to be a defense. To her haters Randi is a buffoon, a step above relationship expert, she is too glaringly undeserving of that money; Randi is an obscene counterexample to the logic that the payout mirrors value and self worth. She is a narcissistic injury for everyone else. So she's disparaged in a specific way: she doesn't deserve all that money because she got it from her brother.

VIII.

Not coincidentally, this is the narrative of Davos to the demo that, unlike Randi, will never, ever, ever be rich; but to whom Randi represents a possibility of it: with globalism comes the possibility of a lifestyle independent of your work product, and, more deeply, that your self-worth will finally be recognized by the world that is happy to pay you just for your individuality. Why wouldn't it? Your baby pictures are adorable.

To be clear, it's not a lifestyle that could be independent of your work product-- it has to specifically be independent of your work product, otherwise its based on something other than you and thus wouldn't count. This is why one cannot profit from "nepotism" and "inside information". Those are bad. That they are, in fact, actually bad is besides the point: they are the exemptions which prove you are worth your money.

It's probably unnecessary to point out that this increase in lifestyle is built on the increased work product of whoever will do it for 30 cents an hour, and anyway it is a red herring. The real attraction for us isn't just the lifestyle, but that it systematizes-- it makes normal-- not ever wondering: how come we have more lifestyle when we didn't do more work? How did that happen? In 2008 it was 1933 and six years later it's 1999, what kind of bananastown calendar is this?

no caption is possible

Confused, I run through my checklist: was there a war? No. Did they invent a new technology? No. Was cold fusion discovered? No. Did the aliens come? Don't look at me like that, did they come? Then nothing could possibly explain how we are all worth twice what we were worth in 2009, or even 30% more than we were worth in 2007. "But stock prices aren't based on our worth." Then what do they reflect? Our productivity? Our innovation? A bet on our future prospects? I ask you again: Did the aliens come?

And hence Globalism-- the brand, not the particulars-- is attractive because it is the physical manifestation of the logic of disavowal we already use for everything else.    "I don't know how it happened, but it makes sense. After all, I am worth it." Economics mirrors psychology, as it always must.

So Randi goes to Davos, never once asking why they would want her there? Convincing her demo of underproducing hyperconsumers that capitalism-- controlling capital-- is pointless and mean, but globalism-- doublespoken as "progress", "human rights", "everything is connected"-- that is a noble cause. Remember that the "culture" she thinks she speaks for, including those that hate her-- "the startup culture"-- is premised on starting a business in order to sell the business to someone else.   Of course the idea is to get rich-- which sounds like capitalism, if you're retarded, but observe the message that is being taught: that the necessary correlate to getting rich is to give all the capital to someone else.   The power is traded for the fetish of power. That's not capitalism, it is madness, and apparently Davos and Randi think women especially will heart it. It'll work for a handful of well publicized people pictured above the caption, "$100 billion! You could be next!"-- followed immediately by a story about how worthless the business turned out to be, so of course the goal for you is to sell out ASAP; but the vast majority who have aligned their psychology with this vector will pursue an impossible fantasy at the expense of their labor and their lives. If you don't believe me, believe Lori Gottlieb. This logic recommended to her to drop out of Stanford medical school to join Kibu.com, and now she's a relationship expert.

"But capitalism exploits the worker." I'll take my chances, because when you get a taste of the money but no access to the capital, you are easily seduced by Globalism-- the brand, not the particulars. Hence the Hollywood stars, hence Buffett's grandson, hence Randi Zuckerberg, all who act like they belong there. They do.

Every time you hear the word globalism, you should hear three things: 1. wealth uncoupled from work product. 2. Lifestyle as a reflection of your personal self-worth. 3. You give up control of the capital, and by capital I mean you.    "Do I still get paid?" Sure, but you have to promise to spend more than what we pay. "How will that work?" Don't worry, Visa will explain it all to you.

IX.

It is no coincidence that social media, "everything is connected" (the default is plugged), is a vivid metaphor for globalism, even as so many social media vaginalists think they are against globalism if it is defined as Wall Street.   Propaganda doesn't care about your motivations, so long as you act in the required direction.

When social media is branded to men as a positive, the gimmick is that it magnifies their power, e.g. "the hive mind." This brand is reinforced even when it is depicted as bad, e.g. men's increased power to stalk, harass, or bully people. On the other hand, when social media is branded to women with interests and passions but no math skills it's for "finding support" or "community"; nothing powerful is expected to occur there, it's a place to feel safe, "connect" and "have a conversation." Those are not accidents, and they have nothing to do with biology, they are the result of market research and 50 years of very, very bad parenting.

But my generation came of age in a world with social networks... we understand that the business leaders of the future will be three-dimensional personalities whose lives, interests, hobbies and passions outside of work are documented and on display.
===== ====== ===== The Last Psychiatrist: Who's Afraid Of Lil Wayne?

boo

This is a video of Lil Wayne's deposition about some nonsense that is beside the point here.
Big surprise: Lil Wayne doesn't take the proceedings seriously. I know, I had to make sure it was really him, too.
I'm no judge, but he looks like he's in contempt, certainly contemptuous, and at 2:45 makes some serious threats against the lawyer: "you know he [the judge] can't protect you in the real world?"
Watch that part, empathize with the lawyer. How did you feel? Did you feel intimidated?
Note that no one reigns him in, no one stands up to him, no one ends the interview, no one demands nothing. Part of this is deposition theatrics, but even the attorney's demeanor changes, he starts acting the way a person who doesn't want to show he's intimidated starts acting. He gets flustered, he pauses, he backs up. Wayne is 5'4" and by all accounts has chronic bronchitis, but everyone is intimidated by him. Why?

II.
If you met Lil Wayne in a dark alley and he said, "He can't protect you," you would probably wonder who this maniac was talking about and run. But if you were a lawyer at a deposition, you'd be way less scared, and that's because not only are you in a safe environment, but it's your environment, your "frame"-- you have all the power, and he has no power except some assorted Constitutional rights which we all know don't apply to black people anyway. (NB: "black people" is code for "rappers.") If you follow this, then the question simply is, why would you be scared at all? What exists inside you that still surfaces even in the safety of infinite power?
"He might slap you with a bag of weed." There is that.
The first fear is an instinctual one: the lawyer could physically fight back if he had to, but when he looks into those cold eyes, he has a sense that there are no limits, everything is on the table-- from insults to decapitation, anything could happen.   That's the fear of the uncanny, which we experience outside of a horror movie when we face: masks, artificial faces, psychopaths, and even ordinary objects which we are told are uncanny (mirrors, basement freezers.) "I don't know what he's capable of" means "I know very well what he's capable of, and it's everything."
That's the kind of fear that fits a street fight, but it has no place in a court; he may want to decapitate you, but he won't be able to. So why are you afraid?

III.

The interesting thing about being taught that violence is wrong is that of all the lessons we were taught-- no means no, all men are created equal, a bird in the hand is something something-- that lesson actually stuck, it became part of our core identity. Most "normal" people aren't afraid of the consequences of violence (pain) as much as of the violence itself. Fighting itself is bad. The lawyer isn't afraid of getting hurt, he is afraid of there being a fight. Wayne may be the aggressor but the voice inside asks, "what did you do to provoke him? Why didn't you stay away from him?" This fear is so primary that the lawyer backs down from Wayne for Wayne's sake, not to avoid getting hit but so Wayne doesn't have to hit him. Wayne is feared not because he's good at winning fights but because he's good at starting fights, and its oddly been indoctrinated in us that it is everyone else's job not to provoke fights with those you know will fight, even if you're in the right.
I want to point out how this dichotomy is very much predicated on a difference between people, not a sameness, and it's felt to be part of the hardware, not the software. There's you, who "knows better", and there's him, who "fights", and that's just the way it is. And since you "know better" it's your responsibility to not let this get out of hand. Pro-gun proponents can be seen as the logical consequence of this position: ok, I'll accept your societal commandment not to fight, but I want to preserve my right not to have to back down, either. The sad, logical retort to this, and I'm going to term it the "liberal" position not because I'm slamming liberals but because it comes from a place of compassion, though, when I write this out explicitly, is really just a kind of kind of classism: "it's best just to back down from them... because that's they way thems are."
There's your analogy for America's ((silently) passive-) (loudly lamented (but secretly feared)) aggressive post Cold War approach to all other countries. The nested parentheses aren't because I'm a terrible writer, but because those kind of modifications and redoublings are how we unconsciously justify doing things we know we shouldn't-- we modify our positions not to do something but after we have done them. Narcissism can be confusing, the hint is that it operates outside of time.
If you think this fear/foreign policy explains our reticence to attack other countries, you've misunderstood: it just means we don't like being in fights, it doesn't mean we don't like other people being in fights for us. Hence: "allies in the region"; volunteer army; UN Peacekeepers; "adverserial legal system"; talking heads yelling at each other on TV. That's how we work. Chechnyans are violent; Americans are violent by proxy.
But the specific point is the premise upon which this all rests: guy A may be afraid of guy B, but he is more deeply afraid of the existence of a fight; and the only reason he'd be more afraid of "the fight" is if he felt on some level that fighting was wrong, and he could only have learned that from somewhere, was taught it.
To get people to be more afraid of fighting, even in self-defense, than the physical pain of an assault takes a lot of years of training, good thing we jump on it early.
First off: associate getting hit with guilt. Even if it's not your fault, it is still felt like it's your fault, and this can be verified by every woman in a domestic relationship, which is why they stay. This isn't innate, we learn this: your parents hit you only when you do something "wrong"; parents separate their fighting kids, "both of you go to your rooms!"; a schoolyard fight is never judged according to fault, the school punishes both people equally; "zero tolerance" says the institution that cares nothing about justice, only the preservation of power. "Nothing gives you the right to hit another person!" Nothing? Seriously?
The only people who learn that getting hit isn't synonymous with guilt are those who get hit inconsistently, randomly-- having older brothers, abusive parents, constant fights with other kids in the neighborhood, etc.
You'll observe a certain characteristic true of all bullying: the victim never fights back at all. He takes his beating, as if to show that he can take it, his strength is in not being broken. Why not at least throw a few weak punches? This is why the terrible father's typical advice to his bullied son, over the protestations of his useless wife-- "stand up for yourself! Just punch him back, and he won't bother you again!"-- is absolutely correct yet impossible to execute. The problem isn't that the kid is afraid of the bully only, he's (more) afraid of the system-- that he'll get in trouble if he fights back, or that he doesn't trust that system to protect him if he fights back and the bully escalates. The parents and school raised the kid to instinctively be ruled by the system, and now suddenly they are advising him to rebel? The bully's doesn't have this fear, he has already opted out of the system. And so the victim, after getting beat up, hears how it was his fault: "You know he's a jerk, why did you go near him? Just stay away from him." (6)
This is why, on the day that the victim does, finally, "fight back", it isn't by squaring off and throwing an uppercut-- it's overly violent, vicious, excessive, and that's not because he needs to overcome the bully but the bully and the system that in effect was protecting the bully, the system that controls the way he sees the world.
It's very difficult/impossible to raise a kid to be in the system, yet teach him also to fight against that system "sometimes." That was one of the problems with OWS, you can't shut down Wall Street if you have two credit cards in your back pocket. The only way to do this is if you try, on purpose, to raise your kid to be a little bit sociopathic. I realize that this seems like strange advice coming from a psychiatrist, but I'm not a very good psychiatrist. Also, I drink.
The only way to make kids understand that there are legitimate times when they must operate outside the prevailing system is by teaching them that there are even higher systems. (1) I don't specifically mean religion, but some kind of higher ethical duty; for lack of a better term I'll call it a strong superego; which says, without needing to explicitly define every case, "there's a right and a wrong, and you know what it is." (2)

IV.

Somewhat off topic: why do so many "nice" (read: white) teenage girls get horned up over Lil Wayne? "Rebellion against the father?" Assuming she even lived with a father, most fathers aren't rebellion worthy, there are very few staid, formal men with fixed rules requiring breaking. The likely explanation is more instinctual: extremes in appearance signify "the man underneath"-- a secret vulnerability, a tenderness, that will be given only to the one person who "sees" it (never mind a million other girls are seeing it). This is an idea that young women instinctively believe in, that the "ugly" (though to them it's hot) exterior is a mask that must necessarily cover a beautiful interior, in the same way that a "good" young girl, aware that how she looks and acts is a put on hiding her own secret "darkness" (specifically: unlike every other girl in the world, she likes penis), so she assumes that what's on the outside must be the opposite of the inside, until you're over 40 and then inside=outside=soot. Teen boys, with their own identity confusion, meet the girls half way ("you don't know the real me... my secret darkness..." A man with one side tough and one side tender is pretty much a female fantasy, i.e. it no longer exists, except in rappers (rappers is code for black people) and serial killers (and s2 of Dexter is the male version of this adolescent fantasy acted out with knives.)

V.
What's makes this video an example of the consequences of American (=debt based capitalism) parenting is that the lawyer has the advantage of years as a lawyer--AS the system, with all its power-- and yet has that momentary lapse back into a childhood position of scared kid facing a bully. Think Narcissus: nothing before age 26 made that kind of a kid strong, he never earned his power-- he went through the motions, gravity carried him towards the power that was literally handed to him upon graduation, and he believed in it because he had no reason not to. But in that moment with Wayne, we see that his identity as lawyer is put on, a role, which lies on top of the kind of person who still gets intimidated by physical strength, by bullies-- i.e., a kid who was raised in Nicetown, America by otherwise good parents, completely free of any tests that would teach him what kind of a man he was. "I'm a good student." Oh, you should tell Wayne that.
That power of being a lawyer isn't inherent in being a lawyer, it only exists if everyone else believes you have it, and Wayne chose not to believe it, so the lawyer didn't have it.
The whole fight is taking place inside both men's heads, which is why Wayne is winning. So how could the lawyer get over his fear, what would he have to do to not be intimidated?
Flip the question: how is it possible for someone with no power (Wayne) to be able to scare those with more power? The answer is to do what Wayne does instinctively: make the fight into a different kind of fight. He doesn't accept his "role" as defendant, as someone at the mercy of the court's rules. Wayne doesn't just not let himself be intimidated by the lawyer, he doesn't see him as a lawyer, as an agent of a larger, massively powerful structure that could crush him into oblivion. He sees him as a bad of soot he could easily punch. And because the lawyer's power was given to him by the court-- the lawyer doesn't see it as really who he is (he doesn't believe in roles, but identity)-- it is, essentially, paper mache, and Wayne's blows right through it. Wayne makes him doubt himself and his power, and so he responds as a powerless man.
If that seems too theoretical to you, think about it this way: the reason the lawyer chuckles, pauses, his inflection changes, and he asks silly questions (3) isn't just because he is intimidated, but also because the lawyer doesn't want to appear intimidated of Wayne. As if to show he's a man, he tries to meet Wayne halfway, on his terms, he defers to Wayne's power but tries to laugh it off. He tries to pretend that, as a man, he's not afraid of Wayne. That's why it fails. As a man, he is afraid of Wayne, but as a lawyer, he has nothing to fear. Where's the shame in getting beat up by Lil Wayne (never mind the pain)? But that's the lawyer's instinct: not to be seen as weak.
What the lawyer should have done is take control of the context, retreat deeper into the role of agent of the court with all the power. "It doesn't matter if you can beat me up, it doesn't matter if you don't recognize the strength of the court, it exists, and I have it." In other words, to take his physical weakness as a given but irrelevant: so you can beat me up, so what? (4)
-----

1. Note that the message to overthrow a prevailing system, e.g. the government, is in the Declaration Of Independence (following Locke) not just as a right but as an obligation; and it is only able to do this by appealing to "fundamental" rights, "natural law." The point here isn't to argue whether there is a natural laws, only to show a higher system was explicitly codified to facilitate being (from the system's perspective) "sociopathic."
2. The danger, of course, is in the balance between defining and not defining, i.e. if this higher system or superego is not well defined enough, does not possess its own rigid rules or internal logic, then one runs the risk of creating an Enslaved God-- a narcissistic excuse for breaking the lower order rules because it benefits you. ("Stealing is wrong, but in this case...")

3. Either this lawyer isn't very good, or he really was intimidated. Protip: never ask "do you recall..." because a legitimate answer is "no." It should have been straight facts ("did you... is this...?") This is a deposition, not a trial, so as long as this lawyer gets all the facts out and forces Wayne to admit to whatever it is this case is about, he can move for summary judgment and that's the game. But instead of focusing on facts and forcing Wayne to declare his position relative to those facts, he's meandered into the nebulous world of "identity", and has inadvertently made Wayne look interesting, legitimate, authentic-- Wayne is just being Wayne, after all-- thereby helping Wayne's case. You will observe how many comments on the video are pro-Wayne, even though Wayne is unimaginably hatable in this (and all other) videos.

And, continuing from "I am an agent of the court, I have all the power" it is his responsibility to ask the judge to deal with Wayne-- in not doing so, he showed considerable weakness. If you want a TV analogy, here's two: when they depict a psychiatric hospital, the doctor says, "please give the patient this injection" and then the big orderlies/techs have to do the nasty business of restraint, but this doesn't make the doctor appear weak, it makes him appear even more powerful. In this analogy, the judge is the orderly. Second example: the woman who manages to get a gun during the scuffle and points it at the nasty serial killer, only to panic, "stop right there or I'll shoot! I mean it!"-- which serves only to reveal that she is not going to shoot, not intentionally; so as long as the murderer makes no sudden moves he can calmly walk up to her and take the gun, using her ambivalence and fear against her. In this analogy, the judge is the gun. Shoot, stupid.(5)

4. Strategy: Wayne would have lost all his ground if the lawyer had been a woman.

5. The rule for ambivalence (as distinct from questions/decisions/problems) is that it is never resolved by thought, only by action, and that the action chosen is irrelevant.

6. You'll also observe something that you learned completely backwards. If a bully beats you up, it's even worse if you tell on him, if you're a tattle tale, it reveals you to be less of a man (or kid.) But think about this for a second: where did you learn that you'd be less of a man? From the bully. In other words, that threat is entirely for the bully's benefit, it in no way reflects anyone else's reality, yet you bought into it completely. Why? And the answer is that, in the bully's system, in the bully's "frame", telling is a sign of weakness, worse than getting beat up; and since you have agreed to operate in his system, since you have agreed to operate by his rules (say, a fist fight you could never win), in those rules if you don't tell, you at least retain your dignity. Which of course you don't, the whole thing is madness-- to anyone not inside that system. I take this diversion to show you the immense power of "the system" on: how you act, what you want, what you value, what you fear. If narcissism can be spun into something positive-- let's call it stoicism-- the lesson is that your fears and desires have nothing to do with the object before you and everything to do with the "system" you've chosen to be in. (I'd make a pornography reference here, but I'll save it for the book.) My advice to everyone smaller than me (the higher order system) is to always fight back and always defend your neighbors, regardless of the cost.

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===== ====== ===== The Last Psychiatrist: Who Should Pay For Continuing Medical Education?
The money is in the C, not the E.

Dr. Nasrallah, editor of Current Psychiatry, has an editorial "The $1.2 billion CME crisis" asking the above question.

Everyone wanted Pharma out of it. Now they're gone, leaving a large bill unpaid. Oops. Probably should have thought of that first.

(An aside: no one thinks twice about asking unemployed college kids or their parents to pony up $150k of after tax income for tuition alone for medical school, but asking employed doctors to put up hundreds of tax deductible dollars for CME is somehow drunken buffoonery.)

But the real question is, do we need CME at all?

Don't roll your eyes at me, Superfly, I'm serious. If we really need an artificial system to force doctors to stay current, does this do that?

Here's this month's CME post-test, worth 1/20th of the yearly state requirements:

What does this question teach you? Nothing.

Time is not infinite-- whatever time and energy was spent learning this meant you didn't learn something else. So I ask you again-- does this help me stay current and knowledgeable, or less so?

"Ok, some of it's trivial, but it's the best option we have." Again, brainwashing: if something doesn't work, it doesn't matter that it's better than the other things that don't work. Doing nothing is better than doing the wrong thing that costs money.

It isn't evident that this stuff leads you to be a better doctor. There's a case to be made-- and I'm making it-- that this actually makes you a worse doctor.

II.

Docs pay for CME because it absolves them of having to learn what appears to be an overwhelming amount of information on their own. But then CME becomes the exportation of the particular biases of the isolated class of CME writers. I have ten years of Depakote CMEs that were not funded by Abbott to prove it. Do you have any Dilantin or Neurontin ones? No? "But those drugs don't work." Do you know why you know that? The Depakote guys told you.

You know these CME guys are called, without any irony, "thought leaders", right?

Imagine you paid money for a newspaper that selected and organized the information they thought was important, and trivialized/marginalized anything that didn't fit into the "accepted" paradigms-- for example, a third party candidate during an election. Or, imagine you paid a bunch of guys you don't know $100k to select and organize what they think is important to your child's development, based solely on the reputation of the corporation that hired them.

Imagine that.

II.

Here's why you've never questioned the need for "continuing education": it is designed to self-reinforce the impression of ignorance. The focus is on continuing-- which means you're never done. You must always be left with the feeling that you are actually quite ignorant about the "current" information.

An example of this idea is Dr.Nasrallah's very editorial: the full title is "The $1.2B CME Crisis: Can eleemosynary replace industry support?"

Well, he got me on eleemosynary, I'll admit. But then again, he probably got lots of people-- so why use the word?

In that same way, Nasrallah uses eleemosynary in a post about continuing education to convey an impression of refinement and knowledge-- you're not as smart as him. So it would never occur to you to question the need for further education; you're hooked into his musings about who should pay the bill.

IV.

The argument about CME is structured similarly to the general healthcare debate: what ways can we make this affordable but free of bias and misuse? But the focus on cost vs. commercialism ensures no one notices that a lot of this stuff simply isn't necessary. The number one branded drug in the U.S. is Lipitor and you don't need it. But because CME is a $1.5B industry, no one will allow that question to be asked, not by conscious suppression but because of groupthink and brainwashing. Go ahead, try. You'll be dismissed with the "of course" fallacy ("of course, we need some system for continuing education,;of course, we need to keep doctors current; of course, we need a way to track it; of course, the system's not perfect but it's the best we have").

These are the responses given by those anchored in the system, in the Matrix. They never question the premises. Never question the textbook, the Introduction.

And they are the ones you will pay to have as your teachers and leaders.

===== ====== ===== The Last Psychiatrist: Who Would Benefit?

Note the caption at the bottom. This is an interesting cover. No one would ever have thought to create a similar warning about the disastrous consequences of a poor fit for, say, Depakote. We know it has side effects, but using it would never be disastrous, right?
But why would bad therapy be disastrous? If psychiatry is so biologically based that the a bad environment is not the main cause of illness, why should bad therapy be so powerful? If bad parenting can't cause ADHD, how could bad therapy make it worse?

"The Art of Psychotherapy". Ok. But why the "science of pharmacology?" Because we sling "5HT2A" around like we know what we're talking about?
The sentence following that says, "Selecting patients for psychodynamic psychotherapy."    Young, attractive, white females, perhaps? But they didn't mean that, of course. It's just a picture.
Almost no one appreciates-- and no one at all verbalizes-- how deeply the bias in psychiatry penetrates. It is no coincidence that psychiatry has been mixed up with SSI, welfare, criminal responsibility, etc. The "nature vs. nurture" debate is a red herring, a magician's distraction. It allows us never to have to say the following:
If they're rich and intelligent, and can understand how their behaviors impact their moods, we can help them to help themselves. And they won't want to take meds that cause side effects anyway.
But if they're poor or unintelligent, we will never be able to alter their chaotic environment, increase their insight or improve their judgment.    However, such massive societal failure can not be confronted head on; we must leave them with the illusion that behavior is not entirely under volitional control; that their circumstances are independent of their activity; that all men are not created equal. Because without the buffer psychiatry offers, they will demand communism."

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===== ====== ===== The Last Psychiatrist: Why Are Athletes Barely Better Than Their Competitors?

I'll admit I know nothing about sports, so I am asking for help on this one.

In writing the post on Olympic bravado and all around anti-Americanism, I read this an article in Time Magazine about the French vs. American swim teams, the significance of which I did not appreciate until later.

The article wrote,

The French swimmers had promised to "smash" the Americans in the 4 × 100-m freestyle relay, but the U.S. men took the gold with a last-millisecond comeback by anchor Jason Lezak. The team--Michael Phelps, Garrett Weber-Gale, Cullen Jones and Lezak-- smashed the world record by nearly 4 seconds.
So that's impressive, but doesn't that mean that the French also smashed the world record by 4 seconds?

In fact, all of the medal winners beat the world record by almost 4 seconds. Almost every country competing beat the world record.

Yet the difference between gold and silver was 0.08 seconds.

A cursory look over other events revealed this is not uncommon: everyone is suddenly a lot better than the best ever was, but they're still barely better than each other.

So how is it that from one Olympics to the next, there is such massive improvement, yet the difference between each team is still (to me) amazingly small?

It's not a case of the far right of the bell curve, where the most elite athletes are close together in ability. In fact, the bell curve would predict that as you move further to the right, there would be fewer people with similar scores.

It doesn't happen in other areas. The two richest people don't have anywhere near the same amount of money. The two tallest people on earth are different by half a foot. Etc.

My guess is that it must have to do with the competition itself, seeing the other competitors and pushing yourself accordingly. But if that's the case, wouldn't the best thing for coaches to do is train their athletes in isolation, and tell them the other guy is six seconds faster than he actually is?

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===== ====== ===== The Last Psychiatrist: Why Are So Many Psychiatrists From India?

Because they're not.
Odd article in Clinical Psychiatry News about the Match.
Although it doesn't come out and say it, it basically laments the fact that there are so many foreign medical graduates in psychiatry. Which is weird, because there aren't.

As the article correctly indicates, there were 1037 slots available. 983 (95%) were filled. U.S. med school graduates comprised 62%.

The article says:
Another issue that concerns some psychiatrists is "a continued and sustained reliance" on international medical graduates to fill residency slots.
What's so wrong about this perspective is that it misses how slots get filled. The slots don't "exist" and need filling. Slots exist because there's a demand for them. And they get filled by FMGs because they had been filled by FMGs the year before. For example: in 2005, U.S. grads filled 63.6% of the slots. In 2006, it is 62%.

So the question isn't why so many FMGs go into psychiatry. It is a) what is it about U.S. medical education that doesn't prompt U.S. grads to go into psychiatry; and b) do we really need this many psychiatrists?

What we should be thankful for, and Dr. Weissman indicates this, is that by taking in FMGs to residency slots, we don't have to pay to educate them in U.S. medical schools.     Basically, it's free money: some other country paid to educate them, and now they work here. Good for us.

But this should lead us to the next question: why send them to medical school at all? Many argue that foreign medical schools are not as good as U.S. ones. Fine-- then why are they allowed in residencies? And if they are, then you can't say you need a U.S. "level" of education, either.     And if an NP can prescribe, and a psychologist can prescribe, you similarly can't obligate we all go to medical school.

So either we need U.S. med schools, or we don't. There are ramifications to either choice. Choose.
You can find the distribution of residency matches here.

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===== ====== ===== The Last Psychiatrist: Why A Story About Russian Spies Who Use Facebook?

this is called promoting synergy

They did dead drops, passed bags of money to each other, and went to parties. And sympathized with Castro, which is so moronic as to be its own punishment.

high value targets

But they have been charged merely with conspiracy to act as an ===== ====== ===== The Last Psychiatrist: Why Can't Kids Walk Alone To School? Part 1
136 comments on Metafilter about an article on the NYT, and none of them suggest that the problem is that adults are untrustworthy and dangerous.

Via metafilter: a mom, Katie, decides to let her kid walk to school, a move so outrageous that the New York Times is compelled to write an article about it.

" 'She's just so pretty. She's just so ... blond.' A friend said, 'I heard that Jaycee Dugard story and I thought of your daughter.' And they say, 'I'd never do that with my kid: I wouldn't trust my kid with the street,' " said Katie, a stay-at-home mother, who asked that her full identity be withheld to protect her children.

Katie, too, is tormented by the abduction monsters embedded in modern parenting. Yet she wants to encourage her daughter's independence. "Somehow, walking to school has become a political act when it's this uncommon," she said. "Somebody has to be first."

Any parent can sympathize: what if?

But what if... what? Be specific, put some thought into this: are you worried your daughter will cross paths with a Bad Man, or are you worried that your daughter is walking into a world where everyone is an opportunist?

II.

One problem is that we aren't trusting of ourselves as parents. Perhaps the older generations didn't know or care about their shortcomings, but we do, for sure. Have we really done our jobs? Did we teach them enough about the complexities of human nature?   It's easy to say "don't talk to strangers," but how do you tell your kid to watch out for his otherwise good teacher? How do you tell them not to let a cop drive him home? ("Why would you ever tell him that?" A: Why would they ever drive him home?)

It's easier to hover.   Not a judgment, just an observation.

We probably all imagined that when we had kids of our own, we'd teach them how to beat down a bully. Well? I know we dreamed about how we'd teach our kids to escape from bad guys. Did you? Did you teach them how to manipulate their attacker? Or did you leave them to the Wii?   "Well there are just too many other important things--" Oh, you taught him French? Started him on push-ups early? Game theory?

Kids don't ask to be chaperoned; they don't ask to be forbidden from going "down the creek" and they sure as hell don't ask for bike helmets. That's all chosen by the parents. So the question really is, why do parents choose to do this?

Don't misunderstand me: I'm not saying we are failures as parents; I'm saying we are afraid we are. We are insecure that we have adequately prepared kids for life. This insecurity prevents us from letting them experience life. And thus they are actually unprepared, and thus we were right.

III.

"All this helicopter parenting is going to make kids grow up to be wusses."

Maybe, but it's interesting that most people who say this don't have any kids of their own. Parents might agree with the sentiment, but they're still going to buy bike helmets. Geezers may like telling stories of how they had to walk five miles to school in the snow, but I don't know any geezers who would let their grandkids do that today.

Do you see that Katie, quoted above, is hiding her identity "to protect her children?" The world is much smaller. Just like it's easy to imagine calling a guy across the country on a whim, it's not so crazy to imagine a guy buying a $100 LAX to NYC plane ticket for the possibility of free 9 year olds.

IV.

Question: have we squandered the nanoseconds we do spend with our kids by using it to teach them not to judge people by how they look?

Xanax yourself, Caps Lock. We adults do frequently judge people based on how they look, right or wrong. So on the one hand we think we can identify the Bad Men, on the other hand we are aware that we have not taught our kids to do it. So we have to do it for them.

Have we crippled kids, in the name of equanimity? That we don't believe anyway?

Maybe such politically incorrect heuristics are precisely what we should be teaching them, precisely because they have nothing else to go by? I know that not every 50 year old white man with a mustache is a pedophile. You know what else I know? Run.

Heuristics are short cuts that save you from overthinking. Sometimes you need handy, explicit rules so that thinking, education, logic, experience, and civilization don't make you do the wrong thing. A joke by Dave Attell:

If you walk outside and see a naked man running down the street, cock flapping in the wind, you run with that man. Because there's some scary shit coming the other way.

"But not all bad men look like bad men!" I know, but maybe at least steel the kid against some identifiable Bad Men? "But not everyone who looks bad is Bad!" So maybe the kid misses out on the gentle friendship of a mustached IT guy. Oh well. He can have a snow cone instead.

V.

Our insecurity is not unfounded. We barely spend real time with them at all, we get through the time until they go to bed or college, whichever comes first. And we're certainly not anticipating the issues they'll face in their future. What did you tell them about the ethics of killing robot hookers?

Narcissism. We don't see our kids as total human beings, they are still mostly extensions of ourselves. Since we're not sure how well we've prepared them, AND we fail to see their unique strengths because they didn't come from us, we just don't know how they'd react.

Will the kid really not be enticed by a guy with some candy/Playboys/pot? If he tries to grab a six year old and she runs, will she know how to get home?

Or, and I can't believe I'm writing this, if she's 15, will she remember to run?

We're not confident in how we've trained our kids and so we don't train them, reinforcing our insecurity. Meanwhile, we don't see that they're growing up anyway.

Kids are the best, Apu. You can teach them to hate the things you hate. And they practically raise themselves, what with the Internet and all.
Good point. We'd better monitor their internet use, then.

Part 2 here.

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===== ====== ===== The Last Psychiatrist: Are Chinese Mothers Superior To American Mothers?

oops... a simple oversight, I'm sure

"A lot of people," writes Professor Amy Chua of Yale, in the Wall Street Journal,

wonder how Chinese parents raise such stereotypically successful kids. Well, I can tell them, because I've done it. Here are some things my daughters, Sophia and Louisa, were never allowed to do:

• attend a sleepover
• have a playdate
• be in a school play
• complain about not being in a school play
• watch TV or play computer games
• choose their own extracurricular activities
• get any grade less than an A
• not be the No. 1 student in every subject except gym and drama
• play any instrument other than the piano or violin
• not play the piano or violin.

It's hard to argue with success-- one of her daughters is pictured playing piano at Carnegie Hall-- and the kids seem at least ISO 400 happy. So is making them practice 3 hours a day, etc, so terrible?

If you're trying to figure out if her method works or if it is harmful some other way, you're missing the real disease in her thinking. She's not unique. the disease is powerful and prevalent, it is American, but a disease nonetheless. (No, this time it's not narcissism.)

I'll explain what's wrong with her thinking by asking you one simple question, and when I ask it you will know the answer immediately. Then, if you are a parent, in the very next instant your mind will rebel against this answer, it will defend itself against it-- "well, no, it's not so simple--" but I want to you to ignore this counterattack and focus on how readily, reflexively, instinctively you knew the answer to my question. Are you ready to test your soul? Here's the question: what is the point of all this? Making the kids play violin, of being an A student, all the discipline, all of this? Why is she working her kids so hard? You know the answer: college.

She is raising future college students.

Oh, I know that these things will make them better people in the long run, but silently agree that her singular purpose is to get the kids into college. Afterwards she'll want other things for them, sure, but for 18 years she has exactly one goal for them: early decision.

Before you argue the merits of that goal, let's ask ourselves why that is the pivot point in America? I don't know any parents who are desperate to raise better parents or better spouses or even better software engineers, we don't think like that. The few times someone thinks out of the box-- "I want my kid to be a basketball star" "I want my kid to be a Senator" the parent is identified as an unrealistic nut. And while a stated goal might be to raise a future doctor, in truth that's really only an abstract promise-- the 18 year goal is explicitly college. You don't teach your 6 year old to assess acute abdominal pain, do you? Nowhere to put that on an application. No, you teach him piano.

I certainly am not saying forcing them to learn piano is bad, or bad for the kid, or that despite the disease that has infected you it won't benefit the child-- I'm not saying Chua isn't right in her techniques. I am saying that what Chua is advocating is ultimately pointless because it is for a meaningless endeavor. The piano isn't for itself, it's for the "right" college, and for 99% of America the precise college you went to is as irrelevant as the beer you used to lose your virginity. Was it Bud Light or Stella Artois? Same bank account.

I feel you resisting my thesis, but no moment in time, at that moment, seems as important as getting into college, both to the parents and the kids. No one anymore celebrates getting a job even though that really represents your future lifestyle, limitations, experiences, everything.

You want your kid to go to a good college, of course I get it. But that monomania for college has to occur at the expense of something else. How much better/worse off are you that you went to your college and not your friend's college? In this hypothetical you don't play football.

And is that average class at an Ivy really better than the average class at a state school? I've taught at both: no. NB that in my example both the state students and the Ivy students had the same teacher-- me. I know there are differences between schools, I'm not naive, but most of those are social/political/sexual and not educational. An Ivy is "better" because its brand is better, like a car. No I don't mean "hey, they all get you there" I mean that the engine of a Toyota and a Lexus is the same, the difference is the leather seats. You want to pay for brand, go ahead; but the people in the know aren't fooled by your fancy car and windshield sticker and the people who aren't in the know can only praise or envy you, but they're in no position to help you attain your goals.

Don't think I've forgotten how important college is to a high school kid. I remember that despite terrible grades I was, inexplicably, put on the wait list to the University of Chicago. And all I could think was, "I'm going to be Phaedrus!" I didn't give a damn about the education, I was hoping/believing that that college was going to define me, make me into someone I was not. I should have been drafted into an infantry battalion just for that.

II.

"Get back to the piano now," I ordered.
"You can't make me."
"Oh yes, I can."
Back at the piano, Lulu made me pay. She punched, thrashed and kicked. She grabbed the music score and tore it to shreds. I taped the score back together and encased it in a plastic shield so that it could never be destroyed again. Then I hauled Lulu's dollhouse to the car and told her I'd donate it to the Salvation Army piece by piece if she didn't have [the piece] perfect by the next day. When Lulu said, "I thought you were going to the Salvation Army, why are you still here?" I threatened her with no lunch, no dinner... no birthday parties for two, three, four years. When she still kept playing it wrong, I told her she was purposely working herself into a frenzy because she was secretly afraid she couldn't do it. I told her to stop being lazy, cowardly, self-indulgent and pathetic.

Take a step outside the article. This is a woman explaining why Chinese mothers are superior. The thing is, I don't know any Chinese mothers who would ever talk about their families this way, publicly, describe their parenting, brag about it. Never. And then you see it: Amy Chua isn't a Chinese mother, she's an American mother. She had a Chinese mother, but now she's a first generation American, which means she has more in common with Natalie Portman than she does with any recent Chinese immigrant.   As an American, she was raised by the same forces: MTV, Reagan, Clinton, John Hughes movies. She may have reacted differently to those, but they were her experiences.

And what do Americans do? They brand themselves. I have no idea if Amy Chua cares about Viking stoves or Lexus automobiles but clearly her brand is SuperSinoMom and her bling are her kids. When Jay-Z wants to front he makes a video, and when Amy Chua represents she writes a WSJ article. Because that's her demo, you feel me?

Which means this self-serving piece has nothing to do with "how Chinese mothers are superior" but is really a summary of her episode of MTV Cribs. "Welcome to my home, yo, let me show you my gold toilet. It's for peeing and flushing the coke down when the heat comes in the back way."

III.

She meant this next passage to be self-congratulatory, let me know if she succeeded:

"You just don't believe in her [the daughter]," I accused.
"That's ridiculous," Jed said scornfully. "Of course I do."
"Sophia could play the piece when she was this age."
"But Lulu and Sophia are different people," Jed pointed out.
"Oh no, not this," I said, rolling my eyes. "Everyone is special in their special own way," I mimicked sarcastically. "Even losers are special in their own special way. Well don't worry, you don't have to lift a finger. I'm willing to put in as long as it takes, and I'm happy to be the one hated. And you can be the one they adore because you make them pancakes and take them to Yankees games."

Who talks like this? This isn't a 3rd person account, it's her autobiography, these are her words, she chose these words, these are how she saw it all go down: "accused," "scornfully", "rolling my eyes," "sarcastically." That's her impression of the world. She's writing this about her husband.

She can't resist getting in a few jabs at her husband. I cringe when I hear a spouse criticising another spouse in public. Lesson 1: you should never, ever, ever, demean your spouse in front of a commoner, and that's a much more powerful lesson to teach your kids than a decade and a half of Minuet in G.

(sotto voce): my husband is a piece of crap my husband needs his face bitch slapped

And while we're on the subject of her husband, when I Google Earth this guy "Jed" what Chinese province is he going to be from?   Oh, Jed isn't Chinese, he's a Jewish American Yale law professor. Now I can't tell if this woman is a racist or insane. Its ommission can only be deliberate, right? It's almost as if she is trying too hard to convince us not that she's a good mother or a successful woman but Chinese, that's the focus for her, so important is this that she needed to make it public-- which makes me want to bet ten million dollars that her children are being raised Jewish.   Is she publicly broadcasting that she's the Chinese mother stereotype to make up for the SinoSems she's created?

You/she'll say that the Chinese discipline is what makes the kids successful, but that's silly. Given that her husband is a Jewish American equivalent to her Chinese Americanness, why isn't their daughters' successes the result of Jewish fathering? Chua would say that she's the one who made her practice, but she's at work all day just like he is, right? I get that she yells more, ok, mission accomplished, but as a technical matter she's not there all the time, the kids have to be self-motivated, and that self-motivation came not just from the mother, but from growing up in with those parents. Unless she's arguing that the father is pretty much irrelevant? Oh, that is what she's arguing.   Sigh.

What Chua believes has made her kids succeed isn't just that she makes them work hard, but that she is ===== ====== ===== The Last Psychiatrist: Why Did George Sodini Shoot Women?
Assuming his log was actually written by him, here is my best attempt at using it to answer the obvious questions.

Disclaimer: I never met him, didn't do an evaluation of him, etc. Basing this entirely on the log.

My markup of Sodini's log here.

What was the basis of Sodini's rage?

What does Sodini talk about most in his log? Not women, sex, or dating, but time. Time wasted and the lack of a future. He was realizing he had run out of time.

Not only did he not attain his life's goals; he was going backwards. He had had sex and girlfriends in the past; now the years had slipped by, no more "hot hotties" for him. He at least had attained a good job; but now there was a chance he'd be laid off. Even if he wasn't, he realized that his skills as a .NET software developer were becoming obsolete. He had found a church to be a part of; he was then kicked out of the church. All the things in life that defined him were going, going...

The "how to pick up women" books and courses were a Hail Mary longshot. Note that he didn't try these in his 20s or 30s. This was a desperate last ditch attempt at achieving something long lasting. On the videos, it's obvious he's hopeful, optimistic, even excited that this might work-- maybe he had a second chance at women? It failed.

The only thing missing from this list would be being diagnosed with a terminal illness.

All the real things which had defined him were disappearing; all his attempts at making real the things he imagined could define him were being stymied.

At 48, George Sodini was watching himself disappear from the earth.

If he didn't hate women, why did he choose to shoot women?

The note showed obvious anger towards specific people, e.g. family, "Andy," pastor Rick Knapp.

Despite how much anger he had towards them, however, he never confronted them. These individuals probably had no idea he even hated them. He wasn't a confrontational person, he couldn't muster the "balls" (his word) to say something to them. Instead, he vented in private:
"That felt good," he wrote after the Andy tirade. You wouldn't write that if you just yelled at Andy. This is why he put their addresses in his log- the chance someone else would harass them. (Note the anger so many have towards Rick Knapp and religion now-- they're taking Sodini's side, and they don't even know Knapp.)

In short, he was afraid of the people he hated, afraid in the way a 17 year old boy still fears his father, even though he might be stronger than him.

He was resentful of women, but despite media proclamations, there is nothing in the log indicating he hated women. He repeatedly identified that his problem with women was himself, not them-- but he didn't know what exactly his problem was. Nor was he afraid of women-- he wasn't even particularly shy. He liked meeting new people; he was about to chat up to a woman at the gym. However, he didn't really see women as people, as individuals, only as tools for his own validation.

His family, however, were real people.

Just to get the courage to kill people he wasn't afraid of, Sodini had to make practice runs; he even "chickened out" of the plan at one point.

George Sodini was likely too afraid to confront, let alone attack, people more powerful than him. It's fairly typical of mass murderers to therefore choose a nameless proxy for his rage; in this case, the symbols of his wasted years.

In the end, this was the closest level of intimacy he was going to get with them.

Was Sodini a narcissist?

No. Maybe. He had narcissistic traits, but many other traits were very non-narcissistic. It's hard to know-- but that's not the question you want answered.

This is the same problem with postulating any psychiatric diagnosis or label (e.g. autism or Asperger's.) While possible, while it might explain his failure with women-- who knows?-- it does not explain why he killed people. That's what you want to know.

He seems to have been depressed; that might explain suicide, but not homicide.

So whether he was a narcissist or not is less important than asking why he killed people.
I can say with confidence that if he was not psychotic, the violence was the result of narcissism, that specific part of him. There are three characteristics of all narcissistic violence: 1. To the outside observer, it appears to be "first strike," unprovoked, or disproportionate to the situation. To the perpetrator, it is the appropriate amount of response to a perceived attack on identity. (Think 9-11, Columbine, etc.)   No one after a narcissistic rage says, "wow, I guess I went a little overboard."   There is no guilt. 2. It is a response to shame, to failure, to loss of identity. Killing your wife's lover probably isn't narcissistic rage. Killing your wife is. 3. Immersion, singlemindedness; obliviousness to outside factors. Whether it takes three seconds or three hours, all you think about is the violence. The violence is the only thing protecting your identity.

Anger is not a necessary part of rage; euphoria, elation, and even orgasm occur during narcissistic violence.

Did he have low self-esteem?

The core of all narcissism is low self esteem, specifically a misunderstanding of the potential of one's importance in the world, but in any case Sodini did not think he had low self-esteem. The log doesn't say, "I'm a big ugly jerk." It says: I look good, smell good, I have a good job, women like me. Given that all the pieces were intact-- he couldn't understand why he couldn't succeed. The reason was that the intact pieces were not put together correctly. He doesn't tan because he thinks he's ugly, he does it because he thinks young women will like it. But he's 48. Tanning isn't going to make a 48 year old man look any better to young women than high heels on a 48 year old woman is going to entice a young man. At that age, you're either attractive to them, or not. Tiny details like that don't change the picture. Worse, it looks bizarre to everyone else. That's the part he didn't get, though he had a brief glimmer of it: "young women were brutal when I was younger, now they aren't as much, probably because they just see me just as another old man."

He didn't overcompensate by inflating his ego, either: "i'm ok at what I do... not at the top of the class, but I do a good job." No mention of how awesome his biceps are; no disparaging the women as too stupid to realize how awesome his biceps were. He's fairly realistic about himself.

Why didn't he just go to prostitutes, or take one of the "meet a bride trips" to Russia or Southeast Asia?

Prostitutes would have been a temporary physical thrill, but they wouldn't have provided what he needed: validation. He knows prostitutes are in it for the money; likely he figured a "Russian Bride" would be faking it with him as well. The point wasn't sex, it was finding someone to confirm he was worth it. Also, these "outlets" aren't simply condemned by society, they're made fun of. Disappearing is bad enough; being laughed into oblivion is much worse.

If he had had a date with the mystery woman in the html code-- or a date with any woman, could this all have been prevented?

No.

Nothing is predetermined, of course, but history serves as a guide.

First, Sodini did have a date, at t least two confirmed, one a year earlier and another in May.

Second, what George was looking for was someone to love him in spite of himself; e.g. unconditional love that he felt he didn't get from his mother (don't you roll your eyes, he pretty much said it himself.) If his mom didn't love him, how was he going to get anyone else to love him? Answer: he'd have to convince them. By definition, anyone he managed to get to love him could not actually love him- because he had to get her to love him.

Consider the "pick up women" books and courses. He looked at dating as a strategy; he needed to learn the tricks. But he has reasonably good self-insight, so what do you think he would think if the tricks worked? If he succeeded in "getting" a girl, he'd immediately diminish her as inferior: "I had to trick her to get her." He wrote:

He exudes confidence People believe bull shit if delivered WITH CONFIDENCE. Get it??
He thinks the confidence is a trick, not something real. And the words one says to get girls, ahead, etc, are bullshit.

Imagine after tanning for a month and lifting weights, he met a girl at the gym who fell in love with him. Part of his thinking would be that had he not tanned and worked out, she wouldn't have liked him. Sodini was 48. How much longer could the tan and the muscles last?

Was he a pedophile?

Not exactly, though "regressed pedophile" might be technically accurate. His focus on getting girls "20 years younger", or "finding it fun talking to young kids" is just looking for someone naive enough to believe his tricks. He clearly had a sexual interest in fully developed women. Of course, had he managed to convince a 16 year old to like him, he would have to declare to himself: "she's so much more mature than her years."

Was he a religious nut? Did he believe that he would go to Heaven regardless of what he did on Earth?

If we take him at his word, he did believe this. However, why did he choose to believe this, yet simultaneously dismissing everything else in religion as crap?

He chose to believe it not merely because it justified his actions, but because it confirmed he, as an individual, had existed and was worth it. If going to heaven depended on what he did in life-- well, he didn't do anything in life, so he'd be sunk.

But if God had selected him for salvation, then he existed, he was real, there was something about him other than his external life that made him worth saving.    His individuality alone is what got him into heaven.

Correct reasoning of the Christian logic would conclude that if knew he was saved-- his identity validated-- then he didn't need to kill anyone. And if he did kill people, he did it from a selfish place that would imply he wasn't saved after all. It's hard to believe that 13 years in hat church and their bible study, he didn't understand this. He "picked and choosed" a religious doctrine that fit his life, instead of the other way around.

As Sodini insane?

Insanity is a legal term, not a clinical one, and thus must be discussed using relevant laws, i.e. Pennsylvania.

Pennsylvania uses the M'Naughten test to determine insanity:

1. Does the defendant suffer from a mental disease? Who knows? I can say I find no psychosis in his log; and I'm certain that had he gone to trial, there'd be dueling experts saying he did or did not. I see aspects of depression, I don't see bipolar or OCD.

2. Did he know what he was doing, or that what he was doing was wrong? This seems incontrovertible. He planned, changed his mind, conducted practice runs, etc.

In the interest of teaching and public discourse, I'll concoct an insanity defense that fits the available evidence:

An insanity defense would have to show that either this was not a rationally planned operation, or else that he was ill and deluded for over a year. So a defense might be that Sodini's log was actually written all at once, on the day of the shooting (note the web address includes "20090804"). He gave no other hints to people, to internet forums, or even within his published google searches that he was thinking of shooting people. He had bought guns, but it isn't even clear he ever fired them before that day. He appears to have snapped suddenly, all at once, and invented a delusional backstory that made him want to shoot people.

He knew there was something wrong with him (he had googled Avoidant and Schizoid) and described himself as unable to find pleasure in things.

He was 5'10", 155 lbs- though videos and pictures seem to place him considerably heavier.    Did he take steroids? Did he have a disease? In his photo he is waring a red or pink bracelet. Breast cancer, or AIDS?

At some point, the depression was acutely exacerbated by either the physical changes, sleep deprivation (google searches have him up at 3am and again at 5am) and then a self-reported return to drinking, possibly marijuana.

etc.

If you could say something to the future George Sodini's, what would you say?

Murder is wrong. You know that, right? You may think it is less wrong than what you've suffered so far, but it isn't.

Next, with respect to committing mass murder: it won't work. Mass murder is the violent expression of being a pussy. The people killed are almost never the people who actually hurt you-- they are the nameless collateral damage of your fear of confrontation. Every person who Sodini felt hurt him is still alive. Every person he shot was nothing but polite to him, if they had any contact at all. This is almost universally true about mass murderers. In other words, the people who you think hurt you most got punished the least. Is that what you wanted?

The problem is fear. Even with a gun, Sodini was too scared to confront the people who most sacred and enraged him. That's probably where you're at, too. Meanwhile, the scary people get to say, "whew!"

In order to beat them you have to confront the people who are actually hurting you, when they hurt you. When the bully comes around, stand up for yourself. You may get beaten up-- you will get beaten up-- but you won't be a coward. That's the part that counts. Not only will you feel good about yourself, but you will eventually terrify the bullies. There's nothing scarier than a guy who won't stay down.

Next, you should know that mass murder doesn't earn you a place in history, you aren't guaranteeing immortality. The only reason you think it does is because like most Americans, your view of history is tens of years. Do you know who Howard Unruh is? Killed 13 people with a Luger. But the crimes happened in 1949.

Worse, the internet is the new arbiter of memory. A hundred years from now, a person is as likely to come across the name "George Sodini" as he is someone who posts a lot of pics to Flickr, which is to say, not that likely.

The quest for immortality, like insomnia, is mostly in those who fear they haven't accomplished anything. "I need more time." No, you need to do more with the time you were given.

Does media reporting of this cause more shootings to happen?

Yes.

How can the press effectively report without causing more of them?

There's not much, unfortunately. The problem isn't the press, exactly; the problem is our changed relationship to the press as our defacto historians and thought police. They tell us the facts, but frame them in the historical context they think most applicable. But since there is no other "media"-- most stories come from AP and Reuters, for example; and the type of people that go into journalism are of a certain mindset, etc-- they establish the parameters and the language of discussion. It's fourth generation warfare, played out on TV. We want to know about mass shooters because they have been telling us we want to know, and they produce the story in the way we want to hear it.

There are some things the press can do better: report the story straight, like a boring day on Wall Street. No pictures of body bags, no sirens, no swat teams. All that stuff will get out, but don't mainstream it because then those images become the point of the story, and thus the point of committing a crime like this. These things will leak out on the internet, of course, but that's ok: no one is going to say, "I so want to do something that will be remembered only by crazy internet detectives on metafilter." (Unless the perpetrator is a crazy internet detective on metafilter.)

Never, ever, show a picture of the killer on the news (unless it's a manhunt.) The public will find a picture of him if they want to, but by the media displaying it for us, it tells us we need to know it; it tells potential murderers that if they commit a murder, their identity will be the most important part of the story.

In other words, they should report mass shooters the way they reported 9-11-- gross generalizations about "terrorists" and little focus on the backstories of the individual perpetrators (other than Atta, name one hijacker), and massive focus on emergency personnel and victims. Hell, they don't even celebrate it as an attack, they call it by its date. That kind of coverage doesn't inspire copycats. (It doesn't inspire very much of anything, actually.)

Will this happen again?

Yes. This is the generation that wants it to happen again and again. I defy anyone to tell me they overheard someone say the following sentence: "why would anyone want to shoot young women at a health club doing latin dance? It's crazy, it just doesn't make sense!"   Anyone?

No, this is what you hear, everywhere: "I don't condone what Sodini did, but I can understand it..." That feeling is societal. It takes on different forms, sex, politics, etc, but the form is an illusion, the substance is "I'm not the person I thought I'd be; no sees me the way I want to be seen."

It may not be a shooting rampage-- it could be a bombing, or a "politically motivated killing"-- but it's the same: "they" kept "me" down long enough...

It's social justice, narcissism style: everyone deserves what they get, and gets what they deserve.

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===== ====== ===== The Last Psychiatrist: Why Do Autistics Score Poorly On The Eyes Test?

"I think she wants me." Wrong.

Asking what's lacking in an autistic kid is like asking what's lacking in a car. Fuel efficiency? Horns? A duck?

There's no consistency in diagnosis, even though the diagnosis is immensely reliable. That means that ten doctors will all agree a person has "ASD," but that person may look nothing like the other people all who have reliably been diagnosed. This makes offering them treatment even more difficult.

So we have choices: try to refine the diagnostic criteria, or create separable categories, or dig backwards in time to find the "neurodevelopmental deficits" that existed in common.

Trouble is, even an identical, genetically determined, structural pathology-- e.g. "larger cerebellum"-- may result in different phenotypes as each kid will learn different strategies to cope. How, without the eye of God, am I supposed to tell if someone has it?

II.

"Reading the Mind in the Eyes" Test was devised by Simon Baron-Cohen, and revised in 2001 to improve sensitivity. The test is widely employed and widely criticized, but it's useful to understand his logic first.

The test is 36 pictures of eyes like the one above. The woman's eyes, above, have choices:

a) decisive
b) amused
c) aghast
d) bored

The test is here-- but DON'T TAKE IT until you read this whole post first. A similar version for children is here, using the same eyes but different words:

a) made up her mind
b) joking
c) surprised
d) bored

Here is a distribution of scores generated with normals:

In this particular study, the "high functioning autism" group scored 21.9 +/- 6.6.

What does Baron-Cohen think this test tests? One starts from the assumption that ASD is a neurodevelopmental disorder-- i.e. a "static encephalopathy." Something happened early, and though it may not be progressing, it is a physical limitation.

The point of this test is to be able to detect, even in a person who appears normal, whether they have this "static encephalopathy."   Do they have true deficits in social cognition that occurred early but have been masked by learning?

Hence the Eyes test. The test is NOT testing the ability of the person to read faces or interpret their emotions, that's exactly the opposite of the point of it. People can have learned adaptive strategies to get at the right answer. This test is supposed to be immune to those tricks.

This test was conceived of as a test of how well the participant can put themselves into the mind of the other person, and "tune in" to their mental state.

Importantly, this requires that the person understand their own emotions and have language to articulate it, which is what Baron-Cohen and others believe is the core deficiency of ASD: the "absent self." So to do well on the Eyes test, they must not be alexithymic. You can't interpret the eyes as "judgmental" (lacking the "hints" that come from the mouth, forehead, context, etc) unless you understand that emotion in yourself. The relationship between alexithymia and low Eyes Test scores has been directly measured.

For example: do psychopaths have difficulty "tuning into" the mental state of others, or can they do it just fine but don't care? I've always felt the latter, and so I'd predict psychopaths do fine on the Eyes Test. They do. (Which, BTW, speaks to the legal question of sanity.)

III.

Is the test flawed, i.e., does it really detect these pre-learning deficits? Lots of ASD people do well on it, especially women, so the test may not be very sensitive after all. Can we at least say that those who score poorly do have the deficits in social cognition? That the test isn't particularly sensitive, but it is specific?

I have very little experience with ASD patients, but I had occasion over this holiday break to cover an ASD unit. An occupational therapist was explaining this test to me, and we showed some of the eyes to a 6 year old boy with ASD who was hospitalized (his second) for behavioral dyscontrol. The kid got several wrong, for example this one:

Baron-Cohen's theory of autism is predicated on a reduced ability to imagine the thoughts and feelings of the other person substantially because they cannot recognize them in themselves.

So I took the ones he got wrong, and three others that he had gotten right, and asked him to guess again, but this time I told him to imitate the eyes himself. Doing it this way, he got them all right. All of them.

Obviously, this surprised me. Admittedly, it was a slow process, but of interest was why it was slow. I watched him "get into character"-- it took five or so seconds to sculpt his eye muscles, individually, into the proper configuration, but once he had done this the answer came easily.

Which tells me that this kid has the ability not to "learn adaptive strategies" or "fake it till you make it," but truly access his own inner state and then apply it to others, i.e. to truly empathize. What he seemed to be lacking is... practice?

So now I ask you to take the test yourself; when you click "Get Score" it will show you the ones you got wrong. Cover the words, look at the numbers, and then go back and try to imitate the eyes for the ones you got wrong. Did it help?

---

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===== ====== ===== The Last Psychiatrist: Why Do Doctors Accept Gifts, And What Would Happen If They Didn't?

fine, I'll just do psych

Is the acceptance of Pharma gifts/honoraria/grants a way of supplementing an income that the medical student expected he would earn, or expected he deserved, in the future-- that didn't materialize?

Apparently not. A study of medical students found they underestimated their future incomes.

Pre 1980, med students overestimated the salaries. After 1980, they underestimated them. Let it sink in, it's pretty easy to retrofit an explanation: after the healthcare overhaul of the 80s (and the lead up to it), post 1980 medical students were trained by doctors who felt "harmed" by the changes. "Man, it was so much better 5 years ago..." and etc.

The the Clinton years-- both Clintons-- and the prospect of even more severe changes made students even more pessimistic about their salaries.

But think about this. In order for them to have underestimated, what they thought was going to happen must not have actually happened. e.g. a 1993 med student made a prediction based on Hillary Clinton's reforms-- which didn't happen.

So a medical student today, making predictions about the future based on the current health care debates, will either be accurate, or will underestimate.

II.

But, as usual, it's more complicated than that.

That graph shows the means of the students' errors. How variable were the guesses? Hugely. 10% of the 4th year students overestimated the incomes by 40%. Did they go on to take Pharma money?

While most specialties were underestimated, where did students overestimate? Psychiatry, by 23%!

Worse, 10% of first year students overestimated incomes in surgery, pediatrics, and psychiatry by 60%. That would be a life plan oops, solved only by...

So while the proposed reforms in internal medicine didn't happen-- or docs were able to compensate for them-- psychiatry did, in fact, dramatically change. And, not surprisingly (from an economic standpoint) psychiatry found a stop gap.

III.

Along with expectations, there is the reality that doctor salaries (with notable exceptions) have been fairly static since 1969:

even as the cost of living, price of homes, college, etc have gone up. And medical school debt.

But what's not pictured here is how the atual work of medicine has changed, even if the incomes are the same. 1969 psychiatry was slower, more therapy based than today's 15 minute med checks. You read medical journals-- and books-- at work. Now you don't even read your text messages. You can argue the merits of either, but the current system incentivizes doctors to see more patients, faster, for more limited problems. In 1969 a GP would handle multiple problems; now multiple doctors handle each problem. I'd predict that the time spent by all 2010 docs collectively is still less than the one guy spent in 1969.

Could a psychiatrist able to make Pharma money just turn his back on $40k extra a year? It's a cold decision to make when you got one kid in college and another on deck, suddenly public ethics takes a back seat to private ethics: what would you do for your children? Jean Valjean a bakery? Sling crack? Sell it if it was legal?   Rob a crack dealer?   Well, you don't have to yet: just give a lecture about Effexor.

IV.

The part of this that is absent from the healthcare debate is that the people who would most likely complain about the changes in psychiatry are less motivated to do so because their incomes are being supplemented by Pharma.

My point here isn't to engage in an ethical debate, but to bring up the practical one: if you stopped all Pharma money to those that receive most of it-- e.g. academic docs who "also" get grants to do research, etc-- it's almost certain that they would mobilize to demand higher reimbursement rates, not passively accept lower ones. The healthcare debate would be turned upside down, from finding ways to "cut costs" to finding ways to "more fairly reimburse doctors."

"Psychiatrists shouldn't do it only for the money!" Of course, but it's hardly less honorable to not go into psychiatry and go into neurology instead. Leaving it to be staffed by NPs, which is the immediate problem in family practice. Of course I know most psychiatrists don't take/aren't offered Pharma money. But, to repeat, the ones who are likely to be most influential in setting healthcare policy-- academics-- do. As do the academic departments, who rely heavily on grants to pay for salaries, overhead, and that new Research Centre that just went up. I'm not blaming them, they may not even realize just how much of their existence is subsidized by Pharma, I'm simply stating a fact. Stop the Pharma money, and you are quite likely to arouse a sleeping giant. Harvard's gotta eat.

I am almost tempted to wonder if the rise of Pharma money 1996-2008 wasn't consciously encouraged by policymakers precisely to allow the policymakers the cover to get away with the sort of changes that happened in psychiatry. Another mercantilist conspiracy theory, I guess.

No doubt people are going to respond that doctors make plenty of money already. This is not the point. Each individual doctor is making that determination for themselves, even if they're wrong you won't be able to convince them they're wrong. And their perception, wrong or right, is going to drive them to make choices like: take Pharma money, go actually work for Pharma, go to another field, go to another job, do/not do only 15 minute med checks, leave Cleveland for San Francisco, etc.

No doubt, doctors universally would be happier with higher reimbursements and no Pharma money. It's not obvious patients would be better served-- psychoanalysis was not Pharma sponsored-- but things would defintely change in some way.

Time: "The new legislation adds a 10% bonus to primary-care physicians' Medicare reimbursement salaries. But this is nowhere near enough. We need to see a 30% to 50% increase in salaries overall to make any real change in the system," says Dr. Lori Heim, president of the AAFP.
But I'm not sure it's actually possible.

V.

An interesting experiment is to open a forum to solicit practical ideas for reform that takes into account the unintended consequences of the reform, and accounts for them. To crowd source a crowd's problem.

It's an experiment because-- hypothesis-- people don't actually care about practical solutions, they are much more interested in their own anger, and will sabotage a potentially useful forum in order to vent it. They will sabotage the country, just to be able to yell.

If I had to name the specific problem with political debate post 1992, that would be it. And yes, there's a word for it.

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---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Why Fly When You Have Tuberculosis?

Have you heard about the nut who, after being diagnosed with a rare tuberculosis, takes two transatlantic flights? Putting everyone at risk? Especially after doctors managed to track him down in Europe to tell him his tuberculosis strain was "extensively drug [isoniazid and rifampin] resistant" and very dangerous, and ordered him into isolation? Why would this nut do it?
The man told a newspaper he took the first flight from Atlanta to Europe for his wedding, then the second flight home because he feared he might die without treatment in the U.S.
He wasn't in the Sudan, or Kazakhstan-- he was in Italy. And he went to Prague to catch a plane to Canada SO THAT HE COULD DRIVE TO THE U.S.
I suggest everyone think long and hard about this, before we take any further steps down the road towards universal healthcare.   You can't give away what you didn't pay for.

5/31/07 Addendum: AK (see comments) discovered that the guy is actually a personal injury lawyer. That's irony. And his new father-in-law is a CDC doc specializing in... go on, guess...

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===== ====== ===== The Last Psychiatrist: Why I Am Against Mental Health Parity
The U.S. Senate is poised to vote on the Mental Health Parity Act of 2007, a cleverly named piece of legislature which conveys the warming sentiment of equality and progressiveness. But the Act is fatally flawed; not only does it not necessarily help patients, but it will likely worsen an already broken system. It should not be passed.

There are two broad reasons to be against this Act, economic and social.

First, the economic. Looked at generally, it makes no sense to provide equal coverage for something that exists in and of itself-- diabetes, tumors, hypertension, etc-- with something that, whether or not it exists, can be called into existence by the force of a single person's voice.   If 50 psychiatrists say you do not have depression, but I say you do, who is right? But my voice has immediately entitled you to substantial benefits.

It is a fairly simple matter to see how extra hospital days may or may not benefit an acute hyperglycemic crisis; it is entirely subjective whether they help someone with depression. Nor am I being heartless: a psychiatrist may be tempted, out of kindness, sympathy, or expediency ("well, it's Friday, let's just discharge him Monday") to keep a person in the hospital longer if there is no impetus to limit inpatient days. Not only is it not obvious that this is beneficial, but a strong case can be made that it may be detrimental, fostering dependence, confirming a "sick role," etc. To be clear: it may be true that extra days are beneficial, but there is nothing to go on but the judgment of the psychiatrist.

The mistake is providing extra resources with no additional accountability. To improve care, it is necessary to justify the expenditures. I know it seems like we should trust the judgment of the noble doctors, but, well, we can't.   Simply having a deeper well from which to draw does not promote better care, and likely leads to waste. This follows from the most important flaw of the U.S. healthcare system: the user of the money-- the doctor-- has no accountability for the use of the money. In no other business does this uncoupling exist. Why keep hospital days short or use fewer medications at better doses, etc? Why not prescribe two antipsychotics at once, or keep them a few extra days? It's so much easier...

The single solution to this is to remedy the flaw: make doctors in charge of the budget. "Here's how much you can spend per patient. Go."

Simply put, this Act does not guarantee improved care for patients; it guarantees improved payments to psychiatrists. While I am all for getting paid more, we should probably focus on the stated purpose of the Act.

The second, social, problem is more nuanced, but arguably more important. The substantial problem with the bill is that, while it asks for parity in coverage for mental illness, it does not actually define a mental illness. That is left to the individual insurers. Thus, they can choose to cover schizophrenia and not depression; bipolar but not ADHD, etc. Better than nothing, you say? Observe:

If most insurers choose to cover bipolar disorder, but not "straight depression," there is the very real likelihood that psychiatrists will simply diagnose bipolar. This already happens, especially to justify inpatient admission. While numerous "reliable and valid" tools exist to make diagnoses, these are rarely used in everyday practice. In most cases, diagnoses are based on clinician bias, feeling, medication justification, and expediency. So many of the psychiatric disorders end up being treated with the same medications anyway-- antidepressants and antipsychotics-- so why fight a diagnosis?

But the social ramifications of an overdiagnosis of "bipolar disorder"-- or any psychiatric diagnosis-- cannot be overstated. I've mentioned how psychiatry becomes an instrument of social change.   I hardly need repeat the legal ramifications of mis/overdiagnosis; but medicalizing what might otherwise have been labeled and handled as social ills also means that these issues will be handled by people-- doctors-- who have the least resources available to make significant changes. How do you reduce poverty and domestic abuse with Zyprexa?

The current state of insurance coverage for patients is not great by any means; but this Act will not offer any improvements and will cost more. A better Act would be one which ties benefits to outcomes.
I am hardly insensitive to the plight of the mentally ill and their need for psychiatric services. However, the goal should be, specifically, better care for patients, not more money for psychiatry. The two are easily conflated, but they are not necessarily the same. At some point, you have to stop buying people's silence.
----------
Stay tuned for Part 3 of The Most Important Article On Psychiatry You Will Ever Read (here's Part I)

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===== ====== ===== The Last Psychiatrist: Why Is It So Hard To Find A Good Black Man To Marry?

uh oh

Prologue here.

I.

From The Economist:

Imagine that the world consists of 20 men and 20 women. Since the numbers are even, everyone can find a partner. But what happens if you take away one man? You might not think this would make much difference. You would be wrong... With 20 women pursuing 19 men, one woman faces the prospect of spinsterhood. So she ups her game. Perhaps she dresses more seductively. Perhaps she makes an extra effort to be obliging. Somehow or other, she "steals" a man from one of her fellow women. That newly single woman then ups her game, too, to steal a man from someone else. A chain reaction ensues...

1 in 9 black men in their 20s is in jail. And only a third of black women 30-44 are married.    The study, Male Incarceration, The Marriage Market, and Female Outcomes, from which the above hypothetical is drawn estimates that for every percent of incarcerated men, there's a 2.4% drop in marriage rates.

You might say that the educated black women are not likely to marry the kind of men who are being incarcerated.   Maybe, but besides the point: the key statistic is that 96% of black women marry black men, and if 10% are in jail, well, what is she supposed to do?

II.

Actually, it's not besides the point, it is the point. Other studies have tried to correlate the quality of eligible men to the overall marriage rate-- i.e. where are all the "good" black men? (Un)Surprisingly, they have mostly found little overall effect, with no explanation. In a normally functioning economy with a dwindling supply, women would be predicted to... settle. But the marriage rate would be high.

This paper is unique, however, because it correlates the actual number of men-- indeed, men precisely not high on the list of choice mates. Their absence has an effect not on the women, but on the men. There's less incentive to try harder. Or try at all.

Here's the missing sentence from The Economist quote:

A chain reaction ensues.Before long, every woman has to try harder, and every man can relax a little.

III.

Do I need to bring up the fact that a lot of (black) people spend months, sometimes years, in jail-- pre trial? Only to have a bench trial with a public defender who does not know their name, and who urges them to take the plea with time served?

IV.

Here's an illustrative example: 70% of black babies are born out of wedlock. They're obviously not all sired by inmates, so how does this happen? According to the study, the decreased pool of men- any men-- means the ones left become more valuable independent of their actual "quality" (as defined by behavior eligibility, etc.)

"I thought I was a catch," sighs an attractive black female doctor at a hospital in Washington, DC. Black men with good jobs know they are "a hot commodity", she observes. When there are six women chasing one man, "It's like, what are you going to do extra, to get his attention?" Some women offer sex on the first date, she says, which makes life harder for those who prefer to combine romance with commitment.

V.

There's also the problem of contagion. A black baby may be born into a loving set of educated parents, but what is the effect of simply knowing that a close relative-- say an uncle-- has been in the joint? Or, more commonly, that there are female relatives who have no choice but to raise a child on their own; and there are male relatives who don't have to live with their kids?

When a parent does something, it makes that action a potentiality in the world of the child. A parent who publishes a book-- even one that no one ever reads-- has, at least, placed writing a book into the range of possibilities. It works both ways.

A.

Behavioral economics is so much fun because by reducing the human condition to the impulses of inanimate objects, or at best rhesus monkeys, you get to ignore all that confusing stuff, like pornography, and its obviously non-existent effect on human desires. "They were maximizing a utility function!"   And how.

Anyone else a little nervous about reducing black men to a commodity with binary utility? No? Just me? Sweet.

B.

If you didn't like that thought, you're going to hate this one: why does the black female doctor quoted above think she's "a catch?" Don't yell at me, all Glocks down-- what makes her a catch?

Because she's a doctor? But I don't know (m)any white women who think being a doctor increases their chances of finding a husband, makes them more appealing. Go over to the med school and ask the women what they think they're doing to their marrigeability. "A lot of men don't want a woman who's away all the time." "They're threatened." Or, my personal favorite: "oh my god, all they want are the nurses."

The answer is that since black women have been able to take on the very qualities they want in a man, they assume that the men would value these things in the same way. You may need to revisit that assumption.

C.

You may not be interested in TV, but TV is certainly interested in you. If black men of a certain type are taking their cues from media images, it's safe to assume the same for women. Right?

So what do we have? The unique, mandatory role for all black female personalities-- from Oprah to Wanda Sykes-- is to say "oh no you didn't" and move her neck back and forth sideways. Each woman may do it to varying degrees, and they are certainly allowed to do other things, but it is mandatory that they "keep it real" at least once per broadcast.

For fiction-- always more powerful-- we have: the spectrum of hoes in music videos; there's the strong, quietly suffering, approaching middle age and beyond, and, of course, solitary black woman; and the educated and attractive black woman-- wherein "educated" is a descriptive proxy for "controlling" or "insane bitch." Something on the order of Why Did I Get Married Too?- let's-break-some-shit-because-he-lied bananas.

Let's say that media portrayals of "educated black women that can't get a man to commit"-- that's a brand-- storming over to his job and smashing things because of alleged infidelity does NOT make real women more likely to do this themselves. Fine. What I am certain it does do, however, is make that behavior less terrifying to black men. "Oh well, that's just what they do. She'll get over it."

The First Lady isn't any of these stereotypes, but suffers from the problem of being an actual person and not on CSI or a reality show, and thus can't be a role model. Sorry, I don't make the rules. So young girls can choose between Anita Van Buren or Omarosa. I'll say what you're all thinking: yikes.

...they're just like us?...

But aren't the black women in prime time strong and noble, even if there are only four types? On every medical drama on TV-- ER, Private Practice, Grey's, etc-- the only attractive, well educated females who aren't serially bedding/flooring men with Wicked rapidity are the black women. Every week, the black women struggle with/over the same man; and those men are always the best at what they do, the chiefs, the leaders. At some point, the men inevitably fall for a white woman. Not permanently, of course; nothing is permanently on TV.

Unfortunately for black women, these shows are scripted by white women. If black girls are watching TV, then they're getting their options from white women. The message is: our lot is to have a series of chaotic relationships in the search of a non-existent ideal; yours is to suffer over one.

IV.

The cycle-- for blacks and whites-- only ever gets broken in one of two ways. One is that this generation grows old and dies, and the next one gets its shot.

The second is that generation 1 stops raising generation 2 by proxy. Accept that what you do is more important than who you tell them you are. "I'm taking you to church right after I finish yelling at your mother." Ok, Dad. I'll be in the car.

V.

If a paucity of black men cause women to "up their game," settle, and be alone; and men to assume a cavalier, non-committal posture, one might ask what happens to a society with too many men.

Apparently, not the opposite. Why hasn't it become true that Chinese women are protected, elevated, catered to? That Chinese men have to "up their game" or settle?

It's an interesting question, one that will likely require a Chinese academic researcher to perform a similar study in her own country on her own people.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Why Is Mel Gibson So Angry?

should've stuck to the plan

Time Magazine:

"I've witnessed thousand of arguments at this point and in my opinion this is not typical," says Sharon Rivkin, psychotherapist who specializes in arguments and affairs and is author of last year's Breaking the Argument Cycle. "I think he's got some very serious psychological problems. I think he's dangerous at this point. This goes beyond just a bad relationship. Even if he's been drinking, that's too much... I'll bet every penny I've ever made that he was abusive in all his previous relationships."

Paypal button is on the right, as long as it's under 14 grand it's not reportable.

She couldn't be more wrong, every single word is exactly wrong.

First, this isn't extreme, it's not even uncommon, these rants happen all the time in relationships everywhere. And the men who yell like this are rarely bipolar, panicking, or even drinkers (and if he was drinking, getting sober isn't going to change this.)

Just like Olga, the women aren't screaming back, they are mostly mute (which drives the men bananas) or sporadically say something infuriating. These exact same arguments happen all the time. (This isn't to justify them or lessen their severity.) And I doubt very much that he's dangerous, though he is quite intimidating and scary.

I should write more about this later, but five things that jump out at me:

1. Coiled spring.

Whatever it is he's arguing about is just the switch to bring up every other sleight he's ever experienced, many that don't have anything to do with her (e.g. ex-wife.) It's not that he's been looking for an excuse to yell about those things, but he sees them as logically connected to his arguments now. She thinks, "what does that have to do with anything?" and he thinks, "see, just like this thing!" He's angry at her, but he's really angry at this "pattern of things that are always being done to me."

NB: the one constant in all of your failed endeavors is you.

2. The threat that is a gift.

She accuses him of something (being crazy, being mean) to which he responds, "oh, you think this is crazy/mean? You don't know what mean is!"   I could hurt you, but I'm not, because I'm a good, anyone else this angry would hurt you. Usually, that move is reserved for people you "love," or are jealous of. His expectation is that she will realize how good he is because he's not hurting her, because he is so wrapped up with her, that she will come around: "oh my God, you're right, how could I have been so stupid? I'll make it up to you, let's get someone to videotape us having sex!"

3. Sex, sex, sex, sex, sex, sex. He's not yelling at an ugly chick. You might think that he'd be happy to have her, and one missed blowjob isn't a big deal (apparently she fell asleep before he got to bed.) But that anger isn't about missing the blowjob. It's that she missed a blowjob, but for sure she never missed an opportunity to blow her past boyfriends. She liked giving them blowjobs. She was way more wild, sexual, open with the other guys. Why not him?

Man: Don't show you love me by marrying me, of course people would want to marry me, show me you love me by being a slut for me, the way you were for the other guys! In other words, prove it!

Woman: That doesn't make sense! And I'm way more sexual with you than I've ever been with any other man!

Man: Didn't you one time have sex in a car?! Ah ha!

Woman: What?

Man: And remember that time you had a one night stand with a guy at the beach, right there in the open? See?!

Woman: But didn't you have one night stands in your life...?

Man: Not with you! You never had a one night stand with me! You gave that to someone else! You didn't think I was sexy enough to have a one night stand with!

Woman: ?!??

Man: !!!!

If you've never had that fight, you'll think it impossible. If you have had that fight, exhale; it happens all the time.

4. Violence up to the line, and a peek over

Pulling a gun and punching her in the mouth are abuse, but he's not beating her to a pulp.    (Not justifying it, please follow along.) The violence is explosive and terrifying-- and then restrained. He sounds out of control, he wants to convey the impression he's out of control, but he's not actually uncontrolled. Though sometimes it gets out of control. He wants to hit her, but the point is to show it. He doesn't want to get in trouble for it. He is aware of rule outside himself and fears them. He doesn't want to be known as a guy who hits women.

What would provoke a man like this to actually commit extreme violence? Shame, with backup support. She has to do something to him that destroys the image of him in the eyes of others (gee, like, say, leaking phone tapes) and he has to find enough people willing to do a Chris Rock: "I'm not saying he should have killed her-- but I understand." As long as the violence has less shame than the thing that originally shamed him, it becomes a possibility.

5. Envy

I lost my money, I lost my career, I lost my family... you have big breasts, you're hot, people desire you, you don't desire me, you have all these friend and I have no friends-- but you know, your friends aren't really your friends, only I'm your friend and you don't even desire me--

It would have been much better if your presence around me proved to me and everyone else that I'm awesome. But you're getting older, and so am I, we don't look as good-- and besides, every time they see you they realize you're only with me because I'm Mel Gibson, so everyone envies you but no one envies me, they think I settled for a Russian whore. And the irony of it is... you're not actually a whore so I don't even get that!

Practical solution:

You split up. I know that seems obvious, but even though this kind of a fight is about other baggage, it implies the relationship itself is an outgrowth of that other baggage (e.g. he picked her because to show the world he could still get models) and thus doomed to failure. You don't love each other, you want to love each other.

I'll point out that it is also typical that once these fights start happening, you'll probably stick together for another decade or so.

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===== ====== ===== The Last Psychiatrist: Why Is There So Much Pollen?

I'm bored and horny, which are the same thing

Female trees are not sought after by landscapers (especially in the city) because what makes them pretty-- flowers and fruit-- also makes them considerably high maintenance. Someone has to clean up after them.

So urban landscapers favor male trees-- no flowers. But plenty of pollen.

There are things which complicate allergies in the city.

First is the urban environment: it's concrete and limited. There's nowhere to go, nothing to do, except blow around aimlessly.

Second, because of the cars, etc, there's plenty of carbon dioxide-- essentially fast food for trees-- which makes the trees pollinate even more.

Third-- and if you don't live near a city all you need to do is watch any TV show set in a city-- Grey's Anatomy or CSI NY-- there aren't that many different kinds of trees. The same types are used over and over.   People forget that there are millions of kinds of trees, they expect to see the same 5 or so.

Unlike delicious rum, exposure to the same kinds of pollen over and over makes you more sensitive to it, not less. Certainly if there were more species of tree out there, you wouldn't react as negatively to a repeated presentation of the same kind. But, as said, female trees are deliberately avoided by landscapers. Since you're not used to seeing different kinds of trees, it never quite hits you that this state of affairs is not only unnecessary, it's deliberately manufactured.

But most importantly to the problem of pollination is simply that there aren't any female trees. This makes the male trees pollinate more. Ordinarily, a paucity of female trees would result in a shift in equilibrium, to form more females/less males.

But the landscape isn't natural, it's artificial-- no female trees. So the male trees, instinctively, keep upping their game; they're not aware they're doing it, of course. Nor are they aware that it doesn't make a difference what they do-- because the environment is being manipulated from the outside.

II.

Imagine what kind of upkeep would be necessary if, for some reason, we didn't have any male trees. How much would it cost the city to both remove the male trees while maintaining the female trees, the seeds, etc?   Putting aside environmental concerns, trying to keep up this kind of disequilibrium wouldn't make any economic sense. We'd quite quickly figure out a way to plant some male trees.

III.

Or, this.

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===== ====== ===== The Last Psychiatrist: Why Is This Funny?

Because it's true.
Is the thing going to be serious, or not? If you think not, then monitoring it won't make any difference because it won't be serious. If you think it could be serious, then you should be monitoring it whether or not there are lawyers in the world. Are you saying that the only reason you would take this thing seriously is because of lawyers? Then thank God there are lawyers.
If you blow it off and it turns out to be serious, then you made a mistake, you were wrong. Then becomes the question of whether you were negligent. Would others in your profession have also blown it off? If so, then it wasn't negligence.
Doctors often think that if they don't do something- a test, document a finding, etc-- they'll get sued. "I have to check the level." "I have to document "no suicidality."" "I have do an AIMS test." "I have to give him a copy of the PI." The reason is "I'll get sued if I don't."
But lawyers can't sue you for not doing these things. They only sue you when something bad happens.    If nothing bad happens, you could be drawing penguins in your chart, lawyers will never know.
Forget about lawyers. Be a doctor: do you need to check that thing, or not?
If your clinical behavior is significantly different because of the existence of lawyers, you need a massive overhaul of your thinking and practice. You have lost your way. And patients will suffer.
(See #4.)

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===== ====== ===== The Last Psychiatrist: Why No Progress Will Ever Be Made In Psychiatry
Do the past 50 years, post psychoanalysis, seem like marking time in psychiatry? A series of equally efficacious or toxic treatments being substituted for older versions that are ultimately not any different, all the while hearing the heralds proclaim the incredible advancements in "brain" diseases? Genetics, serotonin, BDNF!

If it seems like countless billions in research money have not changed psychiatry at all over decades, it's because they haven't.

The first question a fertility doctor asks when she can't get pregnant: are you guys having sex?

In an editorial in Primary Psychiatry, Dr. Sussman writes,

I am constantly looking for sources of easily accessed information that may be relevant to clinical decision making, teaching, and writing...
However, just last week I was pleasantly surprised when my colleague at the New York University School of Medicine, David L. Ginsberg, MD, alerted me to a Website I had never visited

The site he had never previously visited turns out to be MedlinePlus. Let's leave that aside.

That it took a Vice Chair for Clinical Affairs to tell another Vice Chair about the existence of this website, leave that aside.

That Dr. Sussman's very first positive comment about MedlinePlus is:

There is no advertising on this Website.
which I assume is meant to indicate it is free of bias, even as the very journal in which he writes and is editor has advertisements that I guess are less threatening than those on websites, leave that aside.

What he wants to do is stay current, as in this example:

My search directed me to a very helpful article² from a neurology journal that I would not otherwise run across. I read the following...

That what he goes on to quote is actually from a consensus paper-- in other words, a secondary source, someone else reviewing the data-- leave that aside as well.

No, wait, hold on: I understand the complexities of medical practice, and that up to the minute investigation of the primary sources is nearly impossible. But you must agree that the general public actually assumes we are incessantly investigating primary sources all the time, the same way they assume football players work out. If they knew that when we prescribed a medication we were not actually using the latest information, not even listening to a drug rep who has current information, but, well, winging it based on what we once thought we knew-- they'd be beyond horrified.

So to be surprised at a review paper must mean he was even more unaware of the primary sources that it reviewed. That's not a problem unique to him, unfortunately, and if the public found out that doctors only half heard about reviews that were published a year ago... leave that aside.

Let's leave all that aside, res ipsa loquitur.

II.

"The finding of worse anatomic and neurodevelopmental outcomes following fetal valproate exposure in multiple studies suggests that it poses a special risk. Thus, it seems prudent not to use valproate as a first choice antiepileptic drug in women of childbearing age. When valproate is employed in women of childbearing potential, dosage should be kept as low as possible since its effect appears to be dose dependent..."
This is the section in the neurology review he found so interesting. Admittedly, to the average psychiatrist, it is interesting. Despite awareness that valproate (Depakote) has significant teratogenic effects, the debate has been whether to stop it when she's pregnant, not whether to use it first line with any woman of childbearing potential.

In fact, the basic argument over the past ten years has been this: it's first line for every bipolar, men and women, at any age. Even kids. And since the teratogenic effects happen in the first few weeks, by the time she discovers she's pregnant it's probably too late anyway, keep using it.

So for a neurology journal to suggest valproate shouldn't even be first line for epilepsy, let alone bipolar, I can see why he'd find it interesting. Fine. Do you know what he says next about this passage, these recommendations? Nothing.

As if this was completely self-evident, no controversy at all. He doesn't say, "hmm, we've been doing it differently for ten years, were we wrong?"

This would be George Bush commenting in his autobiography that the American troops were not given biohazard suits as they were not expected to confront any bio-weapons. Oh, okay.

There's no advancement in psychiatry because there's no real feeling of the validity of what came before. Medicine is fashion.    No one would say, "we were wrong about Depakote in 2001" anymore than one would say "we were wrong about pantyhose in 1980" (NB: I said both.) What they say is, "that's what we did then." No apology necessary.

The science part of psychiatry-- serotonin, kindling, relapse rates-- is only an excuse for marketing; it gives us today's soundbites. Later we'll say something else using the same science, like we make new fashions using the same materials. No one finds this disturbing.

The reason no progress will ever be made is because no one is contributing to the advancement of science, or medicine, they're contributing to their own careers. Not selfishly or meanly, just myopically. They're masturbating. I don't use that word flippantly, either. It is going over the same old ground, over and over, until a climax-- then it is done and you move on as if it never happened. Then it's the next time, and though the technique is mostly the same, the content of the fantasy mostly the same, this time is different, it neither contradicts or repeals, nor does it augment or enhance the previous work. It's just different. But let someone today try and tell you you're doing it wrong...

Arguably, there should be at least a little shame at the end of it, but...

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===== ====== ===== The Last Psychiatrist: Why Parents Hate Parenting

no, i don't hate you, i just hate what I didn't become

New York Magazine's article, All Joy And No Fun: Why Parents Hate Parenting, has 19 million pages of quotes and examples, but no answer.   Too bad; the answer is right there.

Here's how the article starts:

There was a day a few weeks ago when I found my 2½-year-old son sitting on our building doorstep, waiting for me to come home. He spotted me as I was rounding the corner, and the scene that followed was one of inexpressible loveliness, right out of the movie I'd played to myself before actually having a child, with him popping out of his babysitter's arms and barreling down the street to greet me.

For the new readers, that's your sign that there's a contagion nearby, suit up. When a person sees their life as a movie, that means they're the main character and everyone else is merely supporting cast. And when one of the extras-- in this case, the kid-- goes off script, she doesn't just get upset, she has a full blown existential crisis:

I recited the rules of the house (no throwing, no hitting). He picked up another large wooden plank. I ducked. He reached for the screwdriver. The scene ended with a time-out in his crib... Two hundred and 40 seconds earlier, I'd been in a state of pair-bonded bliss; now I was guided by nerves, trawling the cabinets for alcohol. My emotional life looks a lot like this these days. I suspect it does for many parents...
Wow! Her 2½-year-old acts like he's 3½, and four minutes later she's willing to settle for vanilla extract.

It is at this point, only two paragraphs in, that it should have occurred to the writer that the reason "parents are unhappy" may not have anything to do with the kids. That insight, however, most emphatically does not occur to her or anyone connected with the article.

Which is why it is accurate, though mysterious, to say that the reason parents are unhappy is these articles.

II.

To illustrate the unique unhappiness of parents, i.e. NY Magazine parents, the article describes a UCLA study in which researchers analyzed 1500 hours of video from 32 middle class families in their homes. The clip described in the article is this: a mom trying to get her 8 year old son to stop watching TV and do his homework. Ponder that.

The director of research in this study has watched this scene many times. The reason she believes it's so powerful is because it shows how painfully parents experience the pressure of making their children do their schoolwork. They seem to feel this pressure even more acutely than their children feel it themselves.

Powerful, got it? As in pay attention to this clip. You can imagine what the clip shows, we've all been there, some of us on both ends. The clip shows a struggle millions of parents can relate to.

But for that reason, it's quite ordinary. What makes it powerful?

In order to understand the real importance of this clip, forget about what actually happens in the video and focus on what people saw in the video.

This is what the writer of the article saw:

It's a weekday evening, and the mother in this videotape, a trim brunette with her hair in a bun and glasses propped up on her head, has already worked a full day and made dinner. Now she is approaching her 8-year-old son, the oldest of two, who's seated at the computer in the den, absorbed in a movie. At issue is his homework, which he still hasn't done.

No, that's not the issue, it barely receives a mention. Maybe it's the rum talking, but am I the only one who read that description of the clip and thought "the mom sounds hot?" That's the issue.   The issue is that she is a trim brunette with a bun, with glasses, with a look, whose relative perfection is being marred by the time burglar in the den. The issue isn't the homework, the issue is her. Trim brunette with glasses and a bun=put together mom who has it all, so why isn't she happy?

I'm not saying that mom thinks that-- I'm saying that the writer of the article thinks that; she devoted the majority of the paragraph and almost all of her emotional energy to describing her. But it's a non-sequitor, if the point is about getting the kid to do homework, what difference does it make how she looks or what she's cooked?

It doesn't. But the writer cannot grasp this, because the main character in the movie is the mom, the story is about her. Surely, how she looks must have some importance.

I hope it requires no elaboration that had the writer chosen to see the clip as a story about a curious but bored child tormented by a descriptionless gadfly, this would have been a very different article indeed. But it wouldn't be in NY Magazine, it would be in Omni.

III.

It would be a pointless act of euthanasia to criticize the article, except that these popular press articles are more than bathroom reading, they are the template for how to think about these social issues, in the same way that you can't think about Obama without resorting to language implanted by CNN or the New York Times. Try it. It's impossible.

These articles offer you the freedom to argue about the conclusions, but trick you into accepting the form of the argument.

Here's an example. Passive readers of this article, e.g. everyone on the toilet, will feel the comparative emphasis of the description of the mom and unconsciously assume it is relevant to the thesis. You're going to read "trim brunette" and infer "put together mom" and then you're going to try to figure out why the "put together mom" is having such trouble with the entropy machine her husband gave her. Whatever conclusion you reach, the form of that conclusion will be, "the reason otherwise well put together moms are not happy is..."

From which you can derive every other insanity common to such articles, which in this case the writer does explicitly for you anyway:

One hates to invoke Scandinavia in stories about child-rearing, but.. If you are no longer fretting about spending too little time with your children after they're born (because you have a year of paid maternity leave), if you're no longer anxious about finding affordable child care once you go back to work (because the state subsidizes it), if you're no longer wondering how to pay for your children's education and health care (because they're free)--well, it stands to reason that your own mental health would improve.
Because, you know, no Scandinavian women ever kill themselves at double the rate of Americans.

None of this will make you a happier parent, let alone a better one. The article itself makes the point that, "parents' dissatisfaction only grew the more money they had, even though they had the purchasing power to buy more child care."   So why bring up Scandinavia? Because it jives with some other incompletely thought out political position?

These articles are cognitive parasites, that's what makes them dangerous. They change the way you think. Even if you disagreed with the conclusion, you're still going to approach this problem from, "why aren't put together moms happy?" This will never lead you to the answer.

The real form of the question, the one that generates the correct answer simply in its asking, is, "why doesn't having kids-- or getting married or getting a better job or getting laid or anything else I try to do-- make me happy?   Oh. I get it. I'll shut up now."

I was sure that color coordinating the baby and the bathroom would make me happier but it didn't... should I have gone with lavender?

IV.

Two other short examples.

As per the article, fathers apparently suffer more than mothers. At first I thought it was because they were single fathers, but no, these were married ones. Not what I would have guessed, but I'm open to new information. Per the article, most arguments a couple has-- "40%"-- are about the kids.

"And that 40 percent is merely the number that was explicitly about ===== ====== ===== The Last Psychiatrist: Why The Latest Season Of Mad Men Blows

Dr. Faye Miller, a marketing psychologist who specializes in figuring out the consumer's hidden motivations, is offering her sympathy to Don Draper for his divorce. "Don't worry, she says, "you'll be married in a year." "What?" he says. "Oh, I'm sorry," she replies, "no one likes to think they're a type."

I tried to switch the channel to A Serbian Film but it hadn't come out yet. I'll accept that Don Draper is a type, but when did he become a caricature of a type? End of Season 3?

Gone are the subtle distinctions between a womanizing bastard who seduces everyone and the womanizing bastard who seduces everyone except certain women because you shouldn't. Gone are any subtleties whatsoever, this is a CBS spinoff about good guys vs. bad guys. (Spoiler: the bad guys are wearing ties.)

Here's a race example: In Season 1 there was was a scene in which young Pete Campbell is trying to get some insight into the African American market by asking the elevator operator a few "innocuous" questions, but the operator ain't going out like that. He knows that any conversation with a white executive can go all kinds of sideways, and he has to trickily be respectful while not saying a damn thing.   It's a great scene, discussed from many perspectives all over the internet.

Here's the Season 4 approach to this: four white guys are sitting at a Christmas party, and one says, "if they pass civil rights, it'll be a slippery slope." That's all he says. Get it? White male privilege. Never mind that the phrase "slippery slope" wasn't in popular rotation in the sixties-- it's only there to call to mind its use by the cast of Fox News and The Supreme Court who cry "slippery slope" at every progressive agenda.   Got it.

It only gets better, i.e. worse. Here is another guy's immediate response to that comment: "If they pass Medicare, they won't stop until they ban personal property." Because white men are too dumb to embrace Medicare. Ok. But how is that a response to the civil rights comment? Who has conversations like that? Not even the Fox News improv troupe talk in disconnected non-sequitors. "Michael Jordan was the best ever." "I punch animals."    "My eyes smell like barbecue!"

And I'll wager a bottle of rum on this: the writers must have thought they were pretty clever when they wrote the Medicare line to be delivered by guy who played the Chief of Staff on ER.

Ooooohhh. I get it.   It's post-modern, or something.

White people hating on white people, and its derivatives. An old story, frequently played out on NPR, NYT, or wherever this photo is considered interesting:

I'll help you with the context: the brown stuff at the bottom is Saudi Arabia and the black thing in the middle is Maureen Dowd. No, I'm not kidding. Yes, she is great.

Whites hating whites doesn't mean they like blacks, of course, or Arabs or anyone else. It's all about the hate, that's what drives people, not a love of the oppressed but hatred of "oppressors." If that generates the same outcome I guess it's a viable social policy, but it's hard for me to buy into what leads to cognitive dissonance, as with poor Maureen Dowd: she hates America for what we do to them but hates them for what they do to women.   After a night at the Ritz Carlton the solution she comes up with is to agree to the abaya but wear a snorkel at the same time. That'll show 'em.

II.

The often cited draw of Mad Men was its authenticity (uh oh), including character authenticity. The elevator scene shows that Campbell can be ignorant but not malicious-- he thinks he's just getting information, but is reinforcing the social disparity between them. What Campbell asked that elevator operator is on the order of, "hey, what's up with you people and chicken? How can I get you to buy more of it?" which is simultaneously a societal prejudice and a personal observation. That's what makes the scene interesting. Quoting Dave Chappelle: "all this time I thought I liked chicken because it was delicious, turns out I was genetically predisposed to liking it."

Campbell wasn't being purposely demeaning, he was being Campbell, he didn't understand that merely bringing up the question is an act of aggression. That's "show don't tell" writing.

What would have made it very racist (and unbelievable) was if he pretended not to be aware of societal prejudices: "so, tell me... I love chicken... what do you think of chicken...?"

This is where Mad Men is failing. I know racism and sexism are bad, I know they existed, I don't need this show to tell me that. But was every white guy who didn't vote for Kennedy a gigantic POS?    I want you to figure out how to show me how a man in the 1960s can simultaneously be a good person yet still think women are inferior; how he can be a womanizing pig who still respects women enough to give one the coveted office. In other words, I want the character depth of Season 1, not an off-Broadway rendition of The Huffington Post.

III.

The examples are endless: the (parody of the) egotistical client who makes demeans the advertisers on purpose, because he can. Do you think he gets inappropriate with one of the oblivious wives who thinks he's funny/charming/handsome, while the husband stares on helplessly? True/False: is cuckolding implied? Yay obvious.

Or the fall down drunk Don Draper who has sex with his wide-eyed secretary who is just so thrilled to be with this sloppy mess, and so surprised that he would dismiss her the next day. "He was too drunk to see the couch and he didn't even pull his pants down, but he did manage to ejaculate before he even got hard, so I'm ordering dinnerware." Hint: this means men are pigs.

The problem with the current season's approach to the characters is it's using them to describe the era, not using the era to describe the characters. I know what happened in the 1960s, I don't know what happened to Peggy. Tell me that. Season 1 Peggy was exploited and exploiting, I couldn't tell if I wanted to strangle her or Campbell and so I was hooked-- what kind of a woman is this? According to Season 4, she's a budding superhero. Are you telling me they had superheros in the 1960s?
The writers of Mad Men owe their responsibility to the characters, that's why people watch the show. When you pass on this responsibility in order to tackle social issues, then you better have something new to say about them, otherwise why do we care? If I want a 3rd grade approach to gender equality, I have Eat Pray Love.

---

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Why We Are So Obsessed With Culpability vs. Mental Illness

As the thesis of this blog states: psychiatry is politics.

I'd like to offer an idea for consideration.

The reason there's so much give and take about whether Cho was ill or not, and whether he was culpable or not, has to do with what psychiatry actually is: the pressure valve of society.

Our society does not have a good mechanism for dealing with poverty, frustration, and anger. I'm not judging it, I'm not a left wing nut, I'm simply stating a fact; ours is not a custodial society, and it does little to "take care of" (different than help) these people.

So it has psychiatry, it fosters psychiatry, and it creates a psychiatric model in which these SOCIAL ills can be contained.

The inner city mom who smokes daily marijuana to unwind, with three kids who are disruptive, chaotic in school, etc-- society has really nothing to offer her. But it can't let her fester, because eventually there will be a full scale revolution. So it funnels her and her kids and everyone else like her into psychiatry.
Whether she "actually" has "mental illness" or not is besides the point. Without the infrastructure of psychiatry, hers would be an exclusively social problem with no solution. But with the infrastructure of society, her problem is no longer a social problem, and no longer the purview of the government (or fellow man, etc)--it is a medical problem.
Consider that one of the fastest ways for this woman to get welfare-- and ultimately social security-- is for her to go through psychiatry.
So, too, the angry, the violent, the frustrated...
Hence, discussions about whether mental illness reduces culpability are red herrings. It's about reducing culpability, it's about reducing society's obligation to deal with it.
Society is basically saying this (I'll quote myself):
...if they're poor or unintelligent, we will never be able to alter their chaotic environment, increase their insight or improve their judgment.    However, such massive societal failure can not be confronted head on; we must leave them with the illusion that behavior is not entirely under volitional control; that their circumstances are independent of their will; that their inability to progress, and our inability to help them isn't their (or our) fault; that all men are not created equal. Because without the buffer psychiatry offers, they will demand communism.

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===== ====== ===== The Last Psychiatrist: Why We Are Terrible At Math (And Reading Comprehension)

There are 20% more girls than boys in the class. If there are...

You're a teacher in a public school. You give your 3rd graders a worksheet of 50 two digit addition questions, e.g. 43+25. The kid gets 90% of them right. Pass or fail?

II.

Now it's reading comprehension time, you give the kid this:

He gets them all right. So?

III.

The math example, above, is real, and real(ly) scary.

     4 5
+   2 4
______
     6 9

So the kid had done an entire worksheet of these. But what was hidden from view was that the kid had absolutely no idea he was adding 2 digit numbers. He had memorized the mechanics of the process and nothing else. So when he was asked, "if you have 45 beads, and a friend gives you 24 beads, how many beads to you have?" he didn't know to put the numbers on top of each other like the worksheet; what he did was say the number 45 and then start counting on his fingers, 46, 47, 48, 49.... and of course he ran out of fingers and had no idea when to stop, so he guessed.

The problem is that as long as he completed the worksheet, you wouldn't know there was a problem with doing math until it was way too late. If the kid is clever in other ways-- say, fast at finger counting-- he could easily convey the impression that he understands how to add 2 digit numbers, and what that means, and so everyone thinks he's progressing just fine; only to reach a later point when his clever shortcut is too primitive to work. Now suddenly you have a 6th grader who appears to falling behind. But he was never really caught up. I suspect that this almost entirely explains Americans' universal hatred of word problems.

IV.

A second maddeningly infuriating example. There's a summer class of 1st graders with behavioral problems who are learning to read. Granted a unique sample set, but it's the only one I have. Ok, so one boy is reading the story of Aladdin.

I notice that he is reading the words but there's no cadence, there's no rhythm. At times, he'll read the first words of a second sentence into the flow of the first sentence, i.e. "Aladdin took the lamp. Jasmine polished it." becomes "Aladdin, took the lamp Jasmine polished. It..."

However, he is reading the words correctly. So? So the only way you can evaluate his comprehension is to ask him questions, which he answers with little hesitation. Great, he's reading on grade level. Except he's seen the movie. In the story, the King of Thieves crashes the wedding and steals stuff, and you ask, "who is this guy?" and the kid says, "it's Aladdin's father."

"But Aladdin doesn't know this yet, right? He finds that out in the end. Who does Aladdin think it is now?"

"His father?"

The kid can't be faulted for referencing the movie, but it never occurred to the teachers (two of them) that this was going on.

It's the same problem with the manatee story, above. A fast reader with poor comprehension can quickly re-scan the page for the answers. "A+!" Certainly no remedial training needed here." But that works for a paragraph, it doesn't work for 10 pages. I accept that he may get better, but he may not; the point here is that a lack of comprehension goes undetected because he tests well.   By the time it is detected, it's too late.

V.

Which brings me to the real point: it would require the teachers, and the parents, to be looking for these tricks and shortcuts that kids use, and to "test" the kids in specific ways. The immediate answer you get is, "look, in a class of 20 kids, there's just no way to test kids individually like that." That's not the problem I'm citing here.

The problem I'm citing is that the teachers and the parents don't understand math either, because they used these shortcuts when they were kids. I'm sure adults think they have excellent reading comprehension, but I hope a survey of the universe quickly reveals that they don't. They get the gist.

Try this:

There are 20% more girls in the class than boys. If there are 45 boys, how many girls are there?

Some of you will be daunted by the problem, you don't know where to start. Interestingly, people who aren't "good at math" try and start with some abstract idea of the total. The easier way is to start with what you know, and draw it:

I don't know how applicable this method (Singapore math) is to students in general, but it worked for me and I'm already good at math. And I'm sure there are other methods that are relevant to specific "hangups." But how do you get parents and teachers to be aware of them, let alone use them?

I'm told that the system of the day is "Everyday Math." I have no idea what that is, but my worry is that every system of teaching is designed not to maximize learning, but to facilitate the teaching. Standardize a process among teachers who themselves lack the deepest, intuitive sense of the material. I have no idea what the solution is, though I am open to suggestions.

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===== ====== ===== The Last Psychiatrist: Why We Love Sociopaths

according to this, it's sociopaths that we love

"My greatest regret is I'm not a sociopath," starts an article written by....... well, I reserve judgment. "Are you suggesting...?" No, not at all. That's where the truth lies. "Wait-- 'lies' as in----"

This article is important for a specific reason. If you follow the thesis that The Atlantic and The New Yorker set the default ways which we understand social issues, e.g. sex, money and politics-- and they do this even if you don't read those magazines-- then Kotsko and others like him set the default understanding for academic types. This doesn't mean everyone agrees with him, no no no-- it means that he sets the frame. The trick is you will argue his conclusions but it will be impossible for it to occur to you to argue the form of the question. So "why do we love sociopaths?" is literally understood: "since it is a fact that we love sociopaths, why?"

II.

Kotsko's thesis is that we love sociopaths because sociopathy is opposed to social awkwardness. Say you're in line at the store and some jerk cuts in front of you, on purpose, and for the sake of clarification let me observe he has a Celtic cross tattooed to his shoulder and he just had sex with your girlfriend. He's a different kind of person than you. He can do things you can't, do women you can't, he sees the world's rules differently, which specifically means he understands that there are no "world's rules," that rules are decided by those with power for their own benefit. After he cuts in line, he pockets a Milky Way bar because, well, because he got away with it. My grammar is correct: he can do it since he got away with it.
Ultimately, the only thing you have over him, as you seethe expressionlessly with your 15 items or less, is sleeves and the feeling that you're not a jerk.

The media offers us our wish fulfillment by creating characters who are "good" sociopaths that we can safely envy, and "good" is defined by The Atlantic as "has an internal code of ethics" and by anyone else as "makes it up as he goes along." TV sociopaths-- Don Draper, Tony Soprano-- seem to be like that guy. They do what they want and aren't bothered that you, a loser, think they're a jerk. The difference between you and them, according to Kotsko, is that they manipulate the social connections whereas you are mired in them. They can detach, you can't. Your only compensation is that you have moral superiority.

But at some point in the breakdown of capitalist society-- it says it right on the cover of his book-- that moral superiority isn't enough. Are you not a person who works hard and plays by the rules? You still want to have nice things, you still want to get nice women, you still want to feel some power, which in a normally functioning society you would be able to get in your own natural way. But when there's unemployment and debt and your wife leaves you, and it looks like these are happening because the social contract has failed, because jerks are taking from you, those real losses aren't sufficiently compensated by "at least I'm not a jerk."   Extend that to Wall Street stealing your savings and feeling no shame, having no punishment, and all we can do is pretend that our moral superiority is enough compensation, and of course it isn't.

Hence the aspirational images of TV sociopaths. How great would it be to just...

If only I didn't give a fuck about anyone or anything, we think--then I would be powerful and free. Then I would be the one with millions of dollars, with the powerful and prestigious job, with more sexual opportunities than I know what to do with.

III.

Kotsko has it backwards.

"If only....." Look deep. There is no if only. They already don't "give a fuck." No one who wishes they could be like Tony Soprano or Don Draper actually cares about anyone. "I care about my mom." No you don't. You'd be sad if she died, of course, but you do not care about her, and I don't need to provide any examples for you to know this is true.
The "social contract has failed" argument is a rationalization. What's troubling them is that they already don't care at all, but they still aren't able to manipulate people the way Tony does. This is reinforced by the sentences that immediately precede "If only...":

If we feel very acutely the force of social pressure, they feel nothing. If we are bound by guilt and obligation, they are completely amoral.

Point to the guy who is both "bound by guilt"-- not shame, but guilt-- and also wants to be Tony Soprano and I'll show you a person who doesn't exist.

To be correct, Kotsko's sentences should be revised: "what the hell is wrong with me that I am exactly like Tony Soprano in every single way, except on execution?" Amoral and impotent is different than amoral and potent, but you're a jerk both ways.
This is how I know that anyone who says, "If only I could live in Mad Men time where you could pinch a girl's ass and not get in trouble for it" is going to be way disappointed if a TARDIS shows up, because they wouldn't pinch them back then, either, not because they are afraid of trouble but because they are afraid of girls. Exhibit A: you know what a TARDIS is.

In a sentence, the problem with his Kotsko's analysis is that it isn't a description of the pathology, it itself is the defense against a hidden pathology. Not: because Wall Street steals and we have no justice, we begin to admire sociopaths. But: because we admire sociopaths, therefore Wall Street is able to steal. Not: because the social contract has unraveled, therefore we wish to be sociopaths. But: because we are sociopaths, therefore the social contract has unraveled. I know this is a very unpopular thing to say, but if you find yourself wanting to be bad because everyone else gets away with it, then the problem isn't everyone else, the problem is you.
No, yelling at me won't make this less true.

IV.

I should point out that Kotsko uses the word "sociopath" incorrectly.

The contemporary fantasy of sociopathy picks and chooses from those characteristics, emphasizing the lack of moral intuition, human empathy, and emotional connection. Far from being the obstacles they would be in real life, these characteristics are what enable the fantasy sociopath to be so amazingly successful.

Everywhere Kotsko uses the word "sociopath" he is more accurately describing "narcissist." He calls them sociopaths because of the way they relate to society, but that would mean that the ebola virus is also a sociopath. Society is the collateral damage of me me me.

Kotsko focuses on this a la carte sociopathy because he admits no one envies actual real life sociopaths. We only envy TV sociopaths-- so he infers that it must be a special selection of sociopathic characteristics we actually admire.

But this the wrong inference to make. The reason TV sociopaths are admired is that they are on TV. They have a story.

Do you really admire Tony Soprano? Which part? His loveless marriage to a crazy person? A mistress who is even crazier? His gigantic belly and panic attacks? The fact that no one actually likes him? That his daughter was dating a black guy? ("I wouldn't have a problem with that." Yes you would if you were Tony.) What part do you admire?
The answer you tell yourself is you admire his power, that he can do whatever he wants. No he can't. The whole show was nothing but repeated examples of how limited his options were. The things you think you admire-- having hot sex with the other crazy woman at his psychiatrist's office, eating microwaved Sysco at Italian restaurants, avoiding his wife-- can be done by anyone, you don't need to be Tony to do it. But when you do it.... it just doesn't feel the same. I know.

What people admire about Tony isn't his freedom; that thing you think is freedom is actually the lack of freedom. His story. His identity-- that he has one, an obvious one, a clear one. Tony Soprano is not free, his behavior is completely tethered to what makes sense for his character. He acts exactly like Tony Soprano would act. That's what people want: the limitations of that identity: if I know who I am, I know what I am capable of, I know my strengths and my limits, I know how I'd react to unknown dangers. And I want other people to know this. If other people know who I am, I wouldn't have to keep proving myself. Strike that: I wouldn't have to prove myself in the first place.
Kotsko makes another mistake in thinking that our admiration of TV sociopaths like Don Draper and Tony Soprano reflects a universal psychology. It doesn't. It only reflects the psychology of the people who like those shows, which isn't a lot of people but is a very specific and vocal group of people: Aspirational 14%. Those people have the unique problem of too much freedom, too much money (which is to say they are still living paycheck to paycheck, but only because they are spending it all on keeping up the identity), too many options and, most importantly, nothing to define them.

The admiration of TV sociopaths is related to this desire of self-identification, and not to a lack of power or a failure of the social contract. The social contract is working just fine for the AMC/Netflix demographic. It does not explain a desire for more power; envy explains it. Not knowing who I am, not knowing what I am supposed to do next and what I am not supposed to bother doing next-- makes us long for characters who know precisely what to do next even if it is the wrong things. They may be flawed, but they are definite. They exist.

V.

Telling a modern American that what they really want is less freedom seems like some dangerous talk, but it is true nonetheless. Cynicism, irony has failed you, but you know no other way to be. Don Draper is an ad man, so going to a "partners' meeting" run formally, by a secretary, doesn't seem bad at all. It seems great. Neither does wearing a suit and tie, every day, and a hat. But your job doesn't define you, so going to a meeting seems stupid, a farce, play acting, so you display a cynical detachment from it. And you're not going to wear a tie for anybody. You know it's stupid, you're not buying this corporate bullshit. This cynical posture is a front, a wall, it protects you from being defined by your actions; but what you don't see is that the very job you think you're undermining still receives the full power of your productivity. That you're unhappy, or cynical, is irrelevant to it. It doesn't care about you. Why should it? You don't even care about yourself.
That's what we envy in Don Draper. That he can exist as himself without ironic detachment, that he can be defined as something. And what they are and what they do match up perfectly, even if it's "bad." The truth you must face, now, immediately, is that if you were put in Draper's clothes, in his relationships, in his job, you yourself would immediately affect that cynical detachment: "A partners' meeting? What for? Come on, I see you guys in the hallways all the time" and you'd be as miserable as you are now. But until you accept this truth about yourself, you'll think changing other things could save you. Tell the truth: did you consider a career in advertising after you watched Mad Men? Then you are lost.
VI.

It's impossible to deconstruct TV shows without considering their complement: advertising. Ads, especially TV commercials, offer the exact opposite of cynical detachment: pure aspiration. So while you resist allowing your career or relationship to define you-- "I'm more than a software engineer!" you beg objects-- cars, clothes, women-- to define you, and of course not actual cars, clothes, or women, but whatever other people have said those things represent. Worse, cynicism and aspirational branding aren't two opposite ends of a pole, they form a cycle: the chasm between your cynical view of real life and the perfect definition of the aspirational images in ads makes you even more cynical towards real life; which drives you further into the safety of branding. Which is why you drink.
The only salvation to this existential crisis is less freedom, not more. The only question is whether you will impose these restrictions on yourself, or you will wait like cattle for someone else to impose them on you. But they will be imposed. It is inevitable.
---

http://twitter.com/thelastpsych

Aspirational 14%, defined
Don Draper Voted "Most Influential Man"

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===== ====== ===== The Last Psychiatrist: Will Lilly's New Glutamate Agonist Antipsychotic Be A Blockbuster?
It really depends on what you're asking. But the answer is yes. But don't by LLY yet.

LY404039 is a highly selective glutamate receptor agonist (mGlu2/3). This receptor controls the release of presynaptic glutamate, so this drug actually decreases the release of glutamate.
LY404039 isn't well absorbed, so a prodrug form of it, called LY2140023 was used. After ingestion, it is hydrolyzed to the active LY404039.
In the main study, 40mg BID was tested against 15mg Zyprexa and placebo. Zyprexa 15mg was only slightly more efficacious than LY2140023. This doesn't mean the new drug is inferior-- it could simply mean equivalent efficacy requires more than 80mg.
The selling point of the drug will be the absence of weight gain-- in fact, there was an average of .5kg lost vs. Zyprexa's .5kg gain. Prolactin, akathisia and other EPS were no different than placebo.
There's the background. Now here's some things you need to know to really assess the drug's potential.
First, this is a glutamate agonist. The logic is that its opposite, PCP-- a glutamate antagonist-- produced psychotic like symptoms: "positive" symptoms of psychosis: hallucinations, thought disorder, delusions, agitation, and some "negative" symptoms: flat affect, anhedonia, emotional withdrawal, etc. All antipsychotics treat postive symptoms (acutely, at least-- tolerance develops quickly.) Negative symptoms are much harder to treat-- atypicals are considered to be better for them (whether they are or not is not the point here.)
In order for this drug to be a meaningful advance, it has to be better for negative symptoms than what exists. In the Nature study, LY2140023 was as good as Zyprexa 15mg in reducing negative symptoms, so this is optimistic, but I want for more than 97 people to get it.
Second: one side effect the authors did not discuss is the 4% rate of increased CPK. CPK increases from antipsychotics indicate that excess muscle rigidity is causing muscle breakdown; muscle proteins then clog up your kidneys, leading to death, a disorder called, neuroleptic malignant syndrome (NMS). In this study, placebo and Zyprexa did not cause increased CPK.   In this era of diabetes and weight gain paranoia, we forget that ten years ago doctors were insanely obsessed with NMS and TD. Forensic lectures to psychiatrists dealt nearly exclusively with suicide and TD/NMS. If this isn't fresh in the minds of residents, it certainly will be in the FDA's. I'd need to see more details about this to see if the FDA would even approve the drug at all, let alone get used by doctors.
But Will It Sell?
Oh, yes.
No one who is not a doctor will believe me, but I swear this is true: whether the drug works or not is irrelevant. What matters is that academics tell us to use them. (And I'm an academic, which is uncomfortable to talk about.)
This is a novel agent, with a novel mechanism of action, and no weight gain. Look back in history at another such drug: Abilify.
It was launched in Nov. 2002. By March 2003, it had 4% market share-- $80M in sales in 2003. By 2004, it made $191M with 10% market share.   In the second quarter of 2007 it made $324M. And most psychiatrists do not have high opinions of Abilify, but they use it because "it doesn't cause diabetes." Zyprexa made $4.4B in 2006, and psychiatry hates it, for God's sake. Think about that.
In terms of the existing atypicals, LY would likely gain at the expense of Abilify-- the other weight neutral drug-- and Zyprexa, which will be generic soon anyway. But docs will use it anyway for the novelty factor and concoct every whacked out pseudo-pharmacological/semiotic reason to use it everywhere.
In Furious Seasons there was some skepticism about antipsychotics being a $12B domestic market. I think $12B may be too low. Remember, antipsychotics aren't going to be just for schizophrenics; they will also be used in "bipolars"-- however we decide to expand that diagnosis-- and as antidepressants. SSRIs are going generic, which means that they will not be used. Each SSRI ran about $4B a year-- that entire market gets catabolized by antipsychotics. And don't forget mood stabilizers (read: Depakote). In the old days (like, Thursday) it was "antidepressant + mood stabilizer+ antipsychotic." Next year it will be "antipsychotic + antipsychotic of different mechanism." I've already spoken of Abiliquel. LY-Quel, anyone? Abilif-LY? Zy-LY?
As an investment, Lilly is no good yet. I don't know how this drug will get past the FDA unless the NMS issue is satisfactorily quashed. Meanwhile, Zyprexa sales won't fall, but there's no growth. 51-56 is the range, enjoy it.

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===== ====== ===== The Last Psychiatrist: Will The Suicide Rate Change As The Population Ages?
The correct question would be: what will they do?

I.

Part 1 here.

The point of the editorial in AJP is that since everybody knows the elderly kill themselves at higher rates, we should go Orange Alert and mobilize America in preparation. Ok.

There are a total of 30000 suicides a year. As you can see, the only group who commit suicide at higher rates as they age are white males. Granted, I don't want white people to die any more than George Bush does, but this increase applies only to them.
Now reread that quote in AJP:
In most countries of the world, older adults kill themselvesat higher rates than any other age group. Given that the leadingedge of the large post-World War II "baby boom" cohort willreach the age of 65 in 2011, demographers predict a rapid risein the number of seniors taking their own lives in subsequentdecades. The need for effective approaches to late-life suicideprevention is pressing.

There's your sleight of hand. If the elderly kill themselves at a given rate, the fact that there are more of them coming shouldn't change the rate, only the number. The trick is that "the suicide rate in the elderly is four times higher" is the only thing dramatic enough to get you NIH grants. If it was reported as an increase in the number of suicides-- a number that in the most apocalyptic scenario would be in the hundreds-- no one would care, and certainly no one would pay for it.

II.
Q: Why do the elderly kill themselves at higher rates?
A: "Ummm.... because they are old and there is nothing left to live for?" That culture-bound moronity exemplifies my point. The old must be more depressed and pessimistic, after all they're too old to enjoy life... or something... (God knows the young are enjoying it all so much.)
And maybe many do feel that way, but maybe they aren't any more intent on dying than the young (who have more non-lethal attempts) but are simply physically weaker and thus more susceptible to dying- even during what they hoped would be a non-lethal attempt?

Q: Why do we expect an increase in the number of elderly people to suicide? Is it a stable suicide rate coupled with an increasing population?

from andrewgbiggs.blogspot.com
Well, the suicide rate has mostly fallen. Also note that the greatest change in rates occurred before the psychopharmacology era. The gazillions spent everywhere post 1960 have done nothing. But as anyone with experience using technical analysis will tell you, we don't know what the hell direction those lines are going next. The above blog discussed the opinion that the rate declined with the creation of Social Security. Or was it the war? Or...
It's hard enough to understand what happened in the past. How is AJP so confident about the future?

III.

First, the suicide rates from different decades are not even comparable. An elderly person today will probably have little resemblance to an elderly person of 2030. Consider:

will economic pressures push the elderly to live longer with their kids/extended families (or vise versa)
or
will family units continue their trajectories towards looser, smaller, and more disjointed (e.g. divorces) affiliations?

will better physical health/sex/financial security lead to more satisfaction in later life
or
will promised better health/sex/financial security not materialize, leading to great pessimism?

will narcissists cling to their lives/youth no matter what; Sex In The City VIII begins filming
or
will narcissists suffer the ultimate of narcissistic injuries?

etc.

IV.
The chief reason that suicide rate predictions fail is that they are based, primarily, on absolutely nothing. Psychological autopsy is a biased interview occurring in a specific historical and cultural moment (e.g. the three generations before the current 40 year olds) not generalizable to the next one. Look at 1930 vs. 1960.
Psychiatric illness is a changing construct. What was MDD in 1930 may in some ways be similar to 2009, but in others it is not. If it is madness to conclude a 2009 suicide must have been mentally ill, it is complete and utter madness to take this conclusion and apply it to 1930, let alone 2030.
Instead of asking how the the hypothetical elderly might act in 30 years, you'd be better to ask how we ===== ====== ===== The Last Psychiatrist: Will You Ever Be Happy?

no

"Participating in society": The Bebe Problem

I once dated a girl who worked at Bebe. Is being hot a prerequisite for the job? Not officially, anyway. But is dressing well required? Of course. And she was definitely dressed well. Didn't have to be Bebe, but it had to be this season and designer. She liked DKNY.

But she was only making, what, $25k/yr? She couldn't possibly afford to dress the way she was expected to dress for that job, not without credit card debt or money from parents or boyfriends. Forget about saving, right? And no, no health insurance.

But there she was. It probably never occurred to her that going into debt in order to keep a job is preposterous, because that's the way it's been done there-- and for receptionists and hostesses and etc, forever.

That's not The Bebe Problem: The Bebe Problem is: she thinks she is choosing to do it.

II.

No one told her she needed to dress like that, exactly. But somehow the job selects for a woman who will. Somehow she received the message that to work in a job like that she needs to dress up equivalently to the VP or partner or owner. And they're great clothes, so she likes it, it helps rationalize the purchases. That helps hide the obligation of it.

It's one thing to dress yourself up as a personal brand. It's another thing when you are being dressed up by someone else as extensions of their brand. And yet another thing when you don't even realize it's happening to you, when you think you're making the choice yourself.

I lied about the Bebe Problem. The real Bebe Problem is that this is happening not just to sales girls, but to everyone.

III.

They saved Pamela Anderson and Kate Gosselin for the end of first episode of Dancing With The Stars. The host, Brooke Burke, said, "and coming up next: she's the most downloaded woman in the world, and she's America's most famous mom!"

I had a moment of nausea, so I put down the rum. Don't both of those descriptions more accurately apply to Pamela Anderson? How is Kate "the mom?"

The whole show is full of moms. Brooke Burke has three kids, and unless she is eating them she is incontrovertibly a better mom than Kate. On the DWTS website, contestant Niecy Nash (2 movies and 3 TV shows) lists "motherhood" as her greatest success in life. But she's not the mom either, because she's black. She's the "oh no he di'nt" girl. TV is all about equality as long as everyone stays in character.

Pam is the sex object, even though she is no longer a sex object, nor does she need to be.

And Kate, who is more accurately described as The Woman Whose Haircut Cures Priapism, represents "the mom." Why? Pam and she both have hair extensions, they've both had plastic surgery, they're both hyperconscious of their appearance and image, so?   Truth be told, I'd let my kids live with Pamela Anderson way before I even let them visit the set of Saw IV that is the Gosselin house. So?

Why is Kate "the mom?" Because she plays a mom on TV.

IV.

DWTS is a reality show, of sorts. What (theoretically) makes the show interesting, apart from the dancing, is you get to see people be themselves not their characters. Pam Anderson is thus an awesome choice, because it's a rare chance to see the real woman behind the icon. Unfortunately, on the first episode she was very nervous, and to mask it she overacted, she pouted and wiggled and bit her lip and went over the top sexy, the way an embarrassed child becomes spastic. She hid behind her character, and in that setting it will make people find her annoying. There are plenty of places other than DWTS or my basement to see her naked, that's not what we're here for. She'd be infinitely more interesting if she was just real, because that's what we want to see.

That's not the case for Kate. You already know what she's like in real life, or meta-real life anyway. If you like Kate and are watching, it's because you want to see a "normal" person get the chance to be famous on TV. The trick is fooling you into thinking she isn't that already.

Pam Anderson already had plastic surgery; Kate got it for the show. That's why People adores her: she's a mom becoming something else. If you find yourself rooting for Kate, because, like People, you think it's great that a regular mom is getting to have fun, then it's a fairly safe bet that you're miserable.

V.

I hope it's obvious that Kate "the mom" is just as manufactured as Pam "the sex bomb." But I'm staring at the TV, I am not drunk or insane or an imbecile, and I am trying my hardest, but even knowing everything I know I cannot stop seeing Kate as The Mom and Pam as The Sex Bomb, it is impossible for me to stop these unconscious, reflexive associations from happening.

If I was a woman of, say, 30, overwhelmed by hidden ambivalence, making next to nothing while spending next to everything, simultaneously unfulfilled by my excellent material possessions while protected from facing my actual social position; if I had to choose a direction in life but realizing that my choice probably didn't matter because the outcome had already been decided by the audience, yeah, I'd be on Abilify, too.

VI.

Someone ask Richard Wilkinson where he would place my ex-girlfriend, or Kate Gosselin, on his continuum of social inequality.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Wine Is Healthy In A New (Or Old) Way

Awesome, just awesome.

It's assumed that the benefits of wine are in part due to the plentiful antioxidants. Problem is, those antioxidants don't actually reach the blood in any appreciable amount. One experiment found that drinking an entire bottle of wine provided less quercetin (a flavonol) than some fried onions or black tea; so drinking one glass (or the USDA's mythical one glass=1/8th of a bottle) isn't going to do much.

But maybe we're looking in the wrong place and at the wrong time.

Kanner does a great series of experiments:

Digestion breaks down lipids into hydroperoxides. (Cooked meats are worse.) The stomach acts as a "bioreactor"-- the longer time the food/fat spends there, the greater the lipid peroxidation.   In other words, a medium New York strip lingering in your belly is, well, bad.

An experiment with rats found that eating a meal soaked in red wine completely blocked the the generation of malondialdehyde, a common lipid peroxidation cytotoxin:

Sorry, I said that wrong. Not only did it block it-- it lowered it. Is anyone writing this down?

I know, I know: this was done on rats.

Well, the experiment was done in humans: humans who ate the meal and drank a 200ml (1/4 bottle) of wine had a 75% reduction in MDA as compared to no wine. Wow.

Ah, but if that was the end of the story, this post would only be suitable for Gawker, or TMZ.com, but certainly not this site. No, there's more:

if the meal was soaked in 15ml de-alcoholized wine before cooking-- we call that marinating here in Giverny-- MDA increases were completely blocked.

Note the max is at hour three-- after that, food is gone.

The likely explanation is that the polyphenols in wine form secondary bonds to either natural muscle MDA (in the food) preventing their absorption; or bonds to the proteolytic enzymes in the stomach, preventing the release of MDA from the muscle.

Some foods may have more antioxidants (e.g. cocoa) but as cocoa is not usually eaten with meals they may not be as beneficial. However, eating fruit with/immediately after your meal may be a very smart thing to do.

While the digestive properties of wine have been assumed for millenia, these studies suggest that how we eat, and when we eat, and what we eat it with, may be as important as the individual food itself.

More on wine from the post that started this thread.

===== ====== ===== The Last Psychiatrist: Wolf Blitzer Is Not An Idiot

It's much worse than that.

Balloon Boy: homemade weather balloon allegedly takes off with 6 year old boy in it, balloon comes down, no boy. The boy is later found hiding in the garage.

Then it is learned that the family are "storm chasers," they had previously been on a reality show called Wife Swap, the boy's name is Falcon and the dad looks like he's trying to look like another storm chaser:

But the jig is up. In an interview with Wolf Blitzer, who asks the child why he didn't come out of hiding when he knew people were looking for him, he looks at his mom and dad and says, hesitatingly, "you guys said... we were doing this for the show."

But Wolf doesn't pick up on it. The father ("oh, man") muddles through the interview-- he's waiting for Wolf to start yelling at him. But it never comes, 900 monitors in The Situation Room's and Wolf Blitzer misses the obvious. The interview finally ends.

There was a flood of emails, apparently, and Wolf gets the family back for a follow up interview, "can you explain what the boy meant?" but by that point the father has had a chance to straighten the kid out.

The conclusion is: The whole thing is a hoax, and Wolf is an idiot.

II.

The other conclusion, if it hasn't already occurred to you it will before you finish reading this sentence, is that Wolf did pick up on it, but let it go anyway.

Here's an analogy, which may seem imperfect, but follow it through. The analogy is when a coworker walks in on two people who are calling him a jerk. Rather than confront the coworker, he pretends he didn't hear it. So now everyone knows he heard it, but everyone is pretending it didn't happen. It's not fear of the other guy, it's a fear of changing the delicate balance of the work environment. All he wants is to get through each day, he didn't ask for drama, he didn't ask to get involved in office politics. None of that stuff matters; the goal is to hold your breath, get paid, go home.

So whenever they pass each other in the hall, they're not just civil, they overcompensate.    "What did you do this weekend, anything?" "Oh, I went down to the bay, my father in law's got a boat." "Yeah? Do you do any fishing?" etc.

They both know it's fake; they both know they hate each other. But if they want to keep working there, if they want the job to get done, then they're both going to have to pretend the thing didn't happen, to play their respective parts. The show must go on.

III.

While people are saying Wolf missed the obvious, in fact it is evident he did not. Here's exactly what was said:

Boy: You guys said that we did this for the show.
Wolf: I- I- I heard what he said-- but I'm not-- it wasn't really clear what was his reasoning why he... he heard you screaming Falcon, Falcon, and I'm sure he heard his mom screaming Falcon, Falcon, but why didn't he come out of the garage at that point?

What happened is that Wolf was in the middle of a story some people suspected was a hoax, but was still being reported as a "thank god he was hiding in the garage" drama. So he tried to protect the story. He tried to pretend he missed the comment so that everyone could go on with the story as it was being told.

If you agree with this, then you have to also face the fact that Wolf didn't consciously plan, "no matter what happens in this interview, I'm going to cover it up"-- it was a reflex, an instinct. Get a drink, think about this: a reporter's instinct wasn't to go for the truth, but to go with the scripted story.

You may think that I'm too much with the rum or too hard on Wolf-- "he seems like such a nice man" but it's not Wolf's fault. He's a cog in the Matrix. The next day Meredith Vieira interviews the family live on the Today show. While the father is denying to her it was a hoax, the boy suddenly says, "mom, I need a cup" and vomits. Vierra's response to this is nothing.   Forget about the implications of the boy's vomiting, she does not even acknowledge that he vomited. Is she heartless? No. She's flustered: her instinct is to preserve the show, like a stage actress, keep the scene going no matter what else happens.

Now take your favorite political issue of the past, oh, I don't know, 25 years, think about all you think you know about it, think about where you truly learned it-- don't lie to yourself, go ahead and google the phrases you use in your arguments and see where they came from-- and despair.

-------

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: Wolf Dad, Tiger Mom, And Why Trying To Be A Good Parent Is A Bad Idea

best mom ever

Part 1 here

The people who read books like Chuas hoping to learn something start from a wrong motivation: they aren't looking to raise better kids, they are looking to be better parents. If you don't see how those are different, your kids do.

By example: the NYT's "Motherlode" section has a year-end summary, 2011: Stories That Changed The Way We Parent. Sounds important. Let's see how many are for the advancement of children versus the pretense of parenting:

Amy Chua
Jerry Sandusky
Gender-Neutral Parenting
HPV Vaccines For Boys
The Digital Classroom
The actual sacrifice of parenting, the one that happens anyway but is resisted bitterly to the dismay of all, I've only really seen described once. I hate quoting famous thinkers explicitly because it puts a distance between the reader and the ideas, it makes them less personal, but sometimes it can't be helped:

Did you see that wonderful melodrama, Stella Dallas with Barbara Stanwyck? She has a daughter who wants to marry into the upper class, but she is an embarrassment to her daughter. So, the mother - on purpose - played an extremely vulgar, promiscuous mother in front of her daughter's lover, so that the daughter could drop her, without guilt. The daughter could be furious with her and marry the rich guy. That's a more difficult sacrifice. It's not "I will make a big sacrifice and remain deep in their heart." No, in making the sacrifice, you risk your reputation itself. Is this an extreme case? No, I think every good parent should do this.

The true temptation of education is how to raise your child by sacrificing your reputation. It's not my son who should admire me as a role model and so on. I'm not saying you should, to be vulgar, masturbate in front of your son in order to appear as an idiot. But, to avoid this trap - the typical pedagogical trap, which is, apparently you want to help your son, but the real goal is to remain the ideal figure for your son - you must sacrifice that.

II.

The book title says he beat his kids into Peking U, but actually he did something else:

"From 3 to 12, kids are mainly animals," he says. "Their humanity and social nature still aren't complete. So you have to use Pavlovian methods to educate them."

This is where all the enlightened humanists in the audience are supposed to freak-out. Kids aren't animals, individuality is important, blah blah, but what's important is the word Pavlovian: his violence is not random, it is not surprising.

I could be wrong, but it appears from these articles that Xiao doesn't beat his kids into Peking U out of anger, but out of a system. Not saying corporal punishment is the way to go, but I am 100% positive it isn't the beating itself that molded the kids, but the very clear rules and consequences, which requires an awesome level of energy, vigilance, and self-control on the parent's part, which is why most people who beat their kids only get high school dropouts. Parenting requires consistency. Protip: this is even more important for The Autistic Child.

This is very similar to the mechanism of (preventing) PTSD: you can be the drunkest parent imaginable, and the kid will make it as long as your terribleness is a known quantity, your immensely violent behavior predictable, and the kid has some control over the consequences, e.g. if he does X he'll get his hand put in a microwave, but if he doesn't do X he won't. As long as the kid can make sense of the story of his life, if he understands its narrative structure-- even if it is made up (Life Is Beautiful)-- he can make it.

Remember the judge who beat his teen daughter?   What made the beating worse is that
it made no sense. The amount of beating had no relationship to her behavior, it was entirely dependent on how he was feeling that day, not what she did. As a judge he had sentencing guidelines for different crimes; as a father he freelanced, and terribly. That's what made it particularly damaging. This is the phrase that accompanies all abusive relationships: "I never know what kind of mood he'll be in." The beatings come from rage, which makes them sound like hate. Xiao beat his kids more than the judge did, but you don't get the feeling that Xiao hates his kids.

III.

Wolf Dad is Chinese, actual Chinese, and his main audience is other Chinese. Well, sort of.

The fact that he attributes, publicly, his children's success to his method suggests that he is not behaving like a Chinese Dad, but a Westernized Dad. Real Chinese dads may tell you that they beat their kids, but they do not go around bragging about their childrens' successes, let alone as a consequence of their awesome parenting. Hence, this is for a very specific Chinese audience, i.e. ones interested in taking credit for their kids' successes, i.e. westernized. Xiao may not let his kids watch TV and Youtube, but I will bet every cent I have his readers do.

Xiao's oldest child, 22-year-old Xiao Yao, has his doubts about his father's methods. "Though Dad likes using traditional educational methods, he may not fully understand the exact forms and he chose his own way...

Not just apply the traditional methods-- understand the methods. Even though he is full-on Chinese, these aren't his methods, he is pretending at them, adopting them. In America, kids of immigrant parents get caught in this fatal loop, too. They partially speak their parents' language, have a fair grasp of the traditions but spent most of their American lives trying to be American. But when they grow up and have their own kids, they try to make their kids more like their parents-- they put them in language classes, they try to saturate them in their heritage, but it's fake and it doesn't stick. How can you expect to make your kid more Chinese than you are? We're back to the fundamental error: why, if the parent got through life without much of the old ways, do they think their kids desperately need what they didn't? And the answer surfaces: it's not for the kids, it's for them. You can make up for the fact you know little of your heritage by having your kid do all the work of adopting it.

The delicate line I'm walking is that teaching them traditions is in itself positive; but they are utter wastes of time when it is for the parent. Amy Chua's kids are being raised "Chinese," but really they're being raised Jewish-- which is also a pretense, they're being raised American. I'm sure they like "authentic" Chinese food from restaurants and know how to spell Hannukah, but the way they think is American. The way she thinks is American. All I need to know is that she identifies Chinese and married a white guy to know that one of her daughters is going to be named Emily or Sophia. Note: not Chinese names, but predictably the names affluent Americanized Asians give their kids. She is oblivious to those forces, yet those are in fact what control her.

I'm not at all criticizing her, Sophia is a beautiful name no matter how common, but when you look at the forces that make "you" you, all of the manufacturing and alchemy you try are weaker than reality. And, if that reality includes a substantial dose of American media, you don't stand a chance.

Americans fear the rise of the China, but that China that you see risen was made by Chinese over 50. Their kids, confused by conflicting cultures pictured on the internet versus outside the window are in no position to "take it from here, Dad, we got this." Those kids who are growing up with money, the young college grads and urbanites who are in possession of the few, but nonetheless inflated employment positions are going to be frustrated when they try to balance their own desire for wealth branding with the minimal opportunities for advancement. America may have been destroyed by its 50 year olds, but it will be resurrected by its 20 year olds. China has the exact opposite demographic problem. China appears to be one generation behind the U.S. in terms of personality disorders, and if the rise of psychiatry over there is any indicator, i.e. the single best indicator ever, boy oh boy are they in for it in 2025.

That's Wolf Dad. His beatings are trivial in comparison to the other, now unrepeatable factors he had going for him and his kids: real estate rich; private tutors and lessons; an expensive "international" high school that was taught in English. That's not Chinese parenting, that's WSJ America parenting.

If he or anyone else want to brand themselves as a "parent," that's their business, I guess, though the Chinese media is now attacking Xiao for finding a loophole in the Chinese system: because his kids were born in the U.S., they get to take an easier entrance exam to Peking U.

But that is the least of China's problems: the real problem for China is that they'll probably go back.

---
http://twitter.com/thelastpsych

See also: Why Parents Hate Parenting

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===== ====== ===== The Last Psychiatrist: Worried About What Kids Will See On The Internet?

Someday-- right now-- your kids, and their friends, will be googling you.

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===== ====== ===== The Last Psychiatrist: Worse Than The Flu

Here's a little case report, about me, a cautionary tale about working too hard.
I had to go to Chicago for a case. It took three days. It took a lot out of me. There was the jet lag, and the work, and skipping meals, and sleep deprivation.   I barely sleep at home, but all I could get in the hotel was 2 hours/night.   I usually drink about 3 cups of coffee (16 oz each-- so I guess that's 6 actual cups) a day, but with this level of stress and tiredeness I was drinking 4-5. And, dare I admit it, I took a Provigil.
I could feel myself getting sick on the last day. Just get through it, I thought. Sick later. Work today.
I got home, exhausted. The next morning I felt sick, wiped out, achy. There you go, I said. I have the flu. I struggled through work, taking naps when I could.
As the day progressed, I got worse. Weakness, tiredness, horrible nausea, headache. I gagged at the thought of food, but I forced myself to at least drink Gatorade. Gatorade is the artificially sweetened sweat of male bicyclists. Every word of that description disgusts me. I drank the purple one.
Day 2 came, and I was worse, not better. Not even the same-- much worse. The headache was ruthless. The nausea had become motion sickness-- turning my head was a lunar launch. The arthralgias, bizarrely, had disappeared-- except in my neck, which had become very painful and stiff. I couldn't turn my head well. I could barely walk, I could barely think.
I went to work.
The weakness and lethargy had also changed-- into narcolepsy. It wasn't weakness-- I was drugged. I fell asleep for only a second at a time, but it overtook me every moment I wasn't active. Driving. Watching TV. Standing at a urinal. On an elevator. During phone calls. I could not stay awake. Simply closing my eyes would drop me into Stage IV sleep. I could still be talking, but if my eyes were closed I was asleep. And what I said was nonsensical.
I was almost helpless. I took Tylenol. Motrin. Tylenol + Motrin. Nothing. And I could not stay awake. The head and neck hurt so much that the only solace was sleep, which I couldn't stop anyway.
What kind of flu was this? And something worried me: why didn't I have a fever?
By day 3 I had what can only be described as the worst headache of my life. The nausea was constant.
Worst. Headache. Of. My. Life.
I rarely get sick, I rarely take pain relievers. I do 3 sets of 50 push ups a day. I'm pretty healthy, and I've never been incapacitated. I only say this as background for my next sentence: I was so sick I could not see.
Light hurt me, hurt my head. I could not look at the monitor, or TV. I wanted to be in a quiet, dark room-- asleep. With morphine. And the medical student in me solved the mystery: headache, stiff neck, photophobia, no fever.    I had finally done what I had been threatening to do for so long: I had popped an aneurysm. I thought: so this is how it ends.

Nausea. Headache. Neck stiffness. Exhaustion.
Exhaustion.
Oh my God, could I be in caffeine withdrawal?
As soon as I thought it, I knew that was it. I couldn't believe it. I'd never felt it before because I'd never not had coffee before. And that first day back, being a little off, I skipped it-- which made me worse, and then the withdrawal hit.
I made some coffee. It smelled like battery acid. I put ice in it and drank it, one cup all at once. I gagged, twice.
Within ten minutes, I was 10% better. In 30 minutes, I was 50% better. In an hour I was 95% cured. From unable to move, to almost complete cure.
Jesus.
The cure was so total, the reversal so profound, that I actually couldn't remember how sick I was. I thought I must have been exaggerating.
So my body reminded me.
Four hours later, I started to feel that motion sickness again. By the fifth hour, I was on the floor again, same stiff neck and headache. And the nausea was worse: the thought of drinking the battery acid again was too much for me.
But I did it. And again, an hour later, I was completely cured.
How "real" is caffeine withdrawal? Clearly, my own experience takes it out of the theoretical realm. But what about:
the average coffee junkie when he goes to the hospital?
the psych patients who smoke 1 or 2 packs a day, 4 or 5 coffees a day, and get admitted on the unit where it's only decaf and a smoke break a shift?
The case reports of neonates born to heavy caffeine drinking mothers, who went into serious withdrawal. Three neonates had caffeine in their urine! Symptoms include irritability, rigidity, hypertonia and hyperreflexia.
And then there are the kids.
What about all those kids who drink a lot of soda-- say, two cans/d (100mg total)--and maybe sometimes they don't get their dose? One study of such 10year olds found that missing one dose of 100mg made them less alert, had more headache, and performed more poorly on cognitive tasks. But how many parents (or doctors) would have thought about this? Another study also found kids in withdrawal got little headache, but get more myalgias than do adults. Who is savvy enough to attirbute these subtleties to caffeine?
Has anyone else wondered if the prevalence of ADHD doesn't parallel caffeine use and sleep deprivation, especially in kids (kids don't take naps anymore)? And remarked that the main treatments are-- stimulants?

Referencing myself: What is the best and healthiest coffee to drink?

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===== ====== ===== The Last Psychiatrist: WOW

Wow. Wow. Fed cuts 50 basis points.
The Fed did the only thing it could do, given the circumstances. Now people can maybe keep their homes, maybe we don't slide into recession.
But oil goes to $93 and gold to $800, and people think twice about buying corn. Meanwhile GS goes to 220 and the Dow to 15000. And the split between rich and poor becomes visibly wider.
Oh, you want a psychiatry angle. Ok. Zero percent chance of universal healthcare in the next 5 years.

(disclosure: long gold, GS, GOOG; short Iran and Angelina Jolie.)

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===== ====== ===== The Last Psychiatrist: Written Authority For Standard Of Care
A doctor gets sued for an adverse Zyprexa outcome.

The case involves an outpatient with depression who received Zyprexa. One week later he had neuroleptic malignant syndrome.

Important elements:

It was July (e.g. hot.)

The patient had originally been given various antidepressants for recurrent Major Depressive Disorder. Final regimen was Effexor XR 150mg/d, Zyprexa 10mg/hs, and Klonopin 1mg twice a day. The psychiatrist documented extensively the risk of diabetes, and sent him for initial blood work, but did not document any discussion about the risk of NMS.

The first symptom was a high fever and malaise. The man went to a medical ER but in reporting his symptoms (fever, weakness), he did not disclose he was on any psychiatric medications (he thought it not pertinent.) Triage nurse took his temperature (103) and gave him Tylenol. By the time the doctor saw him, he felt a little better and the temp was 99.7 The ER discharged him with "fever of unknown origin" but reportedly told him it was "probably the flu."

Continued to feel worse with consistent fever. He called the psychiatrist and told him he had been evaluated by the ER. Importantly, he did not tell the psychiatrist that he had not told the ER that he was on Zyprexa. Psychiatrist told him to continue with Tylenol, etc, and if he got worse to go to the ER, etc, etc.

The next day he collapsed, and brought by ambulance to another ER, where he was ultimately diagnosed and treated for NMS.

The plaintiff alleges, among other things:

NMS is a well known, extremely dangerous, albeit rare, side effect of Zyprexa.
Psychiatrist failed to inform him of the risk of NMS with Zyprexa.
Psychiatrist failed to properly evaluate the patient during the phone contact.
No suit was brought against the first ER, as the plaintiff('s attorney probably) felt the case against them was not as strong because the patient didn't mention any psychaitric medications.

Let's go through some of the points:

Informed Consent:

The patient was not informed of the risks and alternatives.

I'd argue that it's not unusual that a psychiatrist not mention the risk of NMS. There are simply too many side effects (for any drug) for complete "informed consent." Neither is there much room or time for a complete discussion of alternatives. Not disclosing the risk of NMS does not violate the standard of care because reasonably prudent psychiatrists, indeed, the vast majority, do not either. However, it is up to the doctor to be aware of the risks.

Clinical point: the fact that the doctor had extensive documentation about diabetes is a bad thing, not a good thing. Just on number of words alone, it appears that diabetes carried more importance than anything else that happened in that session, let alone NMS. Consider that all notes are real estate: if you devote ten times as much space to diabetes than to "-SI" (no sucidal ideations) then it appears that diabetes was ten times more important to you.

Zyprexa is not indicated for depression.

Irrelevant, of course, but in a trial it is brought up to show the doctor is a cowboy. Remember, a jury of laymen think FDA approval means much more than it does; they are already heavily biased towards this thinking. Try answering this question on the stand: "So the FDA spends millions of dollars deciding indications just so you can ignore it?" This is why (in my opinion) the doctor's defense should not be that he tried approved treatments first, and then tried unapproved treatments, because it confirms that FDA approval means more than it does.

The doctor's argument should simply be that there is considerable evidence supporting it's use, most of psychiatry already does this quite commonly, and is thus well within the standard of care. Period. Otherwise you're expanding the issue to include not just "did you miss NMS?" but "do you even know what you're doing?"

Failure to diagnose NMS:

Doctor says that NMS was "on his mind" as part of the differential diagnosis, but was dismissed because the ER had evaluated him; had he known the ER did not know about the Zyprexa, he would have stopped the Zyprexa and sent him back to the ER.

Is reliance on another doctor a legitimate defense? Only if you are confident the other doctor's care. Would you let your kid stay over some father's house just because that father had kids of his own? Additionally, even if the patient did actually have the flu, it would not preclude having NMS. So the ER's evaluation was an example of information bias: a block of information that seems useful because of its size, but is actually uninformative-- and misleading.

The doctor also stated in his deposition that NMS was unlikely because the patient was already on Klonopin, which, as the treatment for NMS, should have prevented it.

This was bad. Not only is it factually untrue-- Klonopin wouldn't protect against NMS-- it portrays the doctor as uninformed and dangerous. It's an easy attack for the plaintiff's expert. Teaching point: don't say anything at a deposition that can be fact checked unless you're sure of your facts. Leave all that to your expert. Most doctors think they can create such a good defense for themselves at the deposition that the case will be dropped, but that is very unlikely to happen.

Doctor also stated that the patient did not have any other symptoms of NMS: he was clear and logical in the phone interview; the ER also did not note any confusion, nor did the ER note any rigidity The patient complained of nothing else to the doctor.

This is the defense.   Is the standard of care to work up every case of fever (but without confusion or rigidity) for NMS? Would a reasonable psychiatrist send a person to the ER for possible NMS if the only symptom present was a fever? It's also helpful to work backwards: it's unlikely most psychiatrists would have worked up NMS based on fever alone even if the drug was Haldol, which has higher rates of NMS. Ask it another way: how many times do psychiatrists confront fevers in their practice for which they do nothing?

II.

In the course of deciding what is standard of care, plaintiff's will (and should) ask what determines standard of care? What books and journals do they rely upon?

Think about your response. Think about what the plaintiffs are really asking. They want to make sure you are a real expert, using real science, etc. Saying "November 2008 issue of Wired" is not going to work. So how do you respond? How do you convey to them that what you are saying is grounded in established psychiatric knowledge?

You don't. The question is a trap. If you say, "The Textbook of Psychiatry" then you are holding that book up as the standard bearer for everything. "So you're saying he did everything right according to the NMS chapter, but doesn't the other chapter say Zyprexa is not indicated for depression, and has the potential to worsen depression? So why would anyone use it?" Etc.

Here is what I would respond:

No text or person decides "the standard of care." Standard of care is the care ordinarily given by at least a respectable minority of competent practitioners. Psychiatry has guidelines, but they must be interpreted in the context of individual patients. Insurers may have certain requirements for reimbursement, but these are not de facto standards of care; nor should the denial of reimbursement be taken to imply substandard care.

Some regulatory bodies, such as JCAHO, also have guidelines, but these are definitionally "best practices," not "ordinarily used practices." They are at a higher standard; and consequently care that meets JCAHO standards is therefore well within the standard of care.

Importantly, JCAHO standards are about procedures, not judgments. For example, JCAHO has a policy on how to implement restraints and seclusions, but not when to implement them. If an adverse event occurs during a restraint episode, and JCAHO standards were met, then standard of care on how to use them was definitely met (though, again, not meeting JCAHO standards does not necessarily mean standard of care was not met.) However, the decision to use restraints might not be standard of care.

There are many texts psychiatrists use to inform their practice (Gutheil's Clinical Handbook of Psychiatry and the Law, APA's Textbook of Psychiatry, etc) but none of those determine standard of care, ever. This is why we use experts in malpractice cases. Courts use expert testimony for the purpose of determining what is standard of care, and whether care delivered met that standard. An expert will also assist in the determination of whether, to a reasonable degree of medical certainty, the care delivered was the cause of the patient's injury.

Opposing experts will often disagree as to what is standard of care.

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===== ====== ===== The Last Psychiatrist: Wrong About Obama

The most dangerous case of buyer's remorse in history.

I hesitate to write this. Honi soit qui mal y pense. But I fear someone has to.

I.

That Obama would win wasn't a surprise. That people would feel a sense of history and, well, hope, was to be expected; indeed, that was the point of it all.

But instead of the typical, "good game, guys" and hand shakes all around, I watched in amazement as my country went completely insane, on international TV, for everyone to see.

I watched as the media dispensed with any pretense of impartiality. It was as if they were covering the Olympics, America vs. Russia, and the clock was ticking down 5...4...3...2... "Obama's going to win! Obama's going to win! We're about to make history!"

MSNBC's Keith Oberman plunged headfirst into sycophancy, cheering how great a day it was for African-Americans. "We did it!" Really?

Even CNBC reporters, who had all year made it clear they weren't voting for Obama, joined the other stations in blathering about a new age in history. You are familiar with the platitudes, I hardly need repeat them.

Victory celebrations are fine, but am I mistaken that 40% of the country did not vote for him? And that at least a sizable minority of those people do not believe we are now at a new dawn in history? Did these people suddenly evaporate?

That a black man has been elected President is a testament to the power of the nation, yes, I get it. But there's a certain oppressive feeling about it all, as if that mere fact precludes any dissent; as if to feel that this is anything other than a cultural reawakening of America is an outright violation of human rights.

There is an almost complete sense of the moral rightness of the win, as if the 40% of the electorate that didn't vote for him are anyway thrilled with the outcome of the election. 60% win may be a landslide, but it's still an F. It's not something you tape to the refrigerator.

II.

"But so what, let them gloat a while, as long as he does the right thing..."

Let me be clear that there is more here than simply "our candidate won." This is the belief that everything is different now.

The problem is with two terms: "them" and "right things." Without taking a side, at least accept that there are a lot of "thems" and a lot of "right things"-- all of which have their Hopes for Change in Obama.

What is different form other presidencies is that a number of people expect a number of things-- and these things are often contradictory.

Millions of people are not going to be just disappointed, they are going to feel tricked.

A vote for Change-- what if nothing changes? What if the Bilderbergers and ex- Carter administration people bring nothing but More Of The Same AND Less Of Everything? Do you say, "well, I guess that didn't go as planned" or do you become so jaded about the political process that your anger turns generalized? Paranoid?

Remember, this wasn't John Kerry, the man chosen because he was supposedly more palatable than Howard Dean; this was everyone's first choice, this is exactly the guy they wanted, with completely rational expectations that he was going to at least attempt to deliver.

But-- sit down, think about this for a minute-- what happens if he fails? Not fails in his attempts, but fails to attempt the things everyone expects him to accomplish? What if he succeeds in doing the opposite of what you thought he would attempt?

How long before people move away from scapegoats, and attack the system that (they believe) uses them, tricks them, tricked everyone into accepting Barack Obama, figurehead, so the "powers that be" can go on with their plans?

Hating George Bush was a popular pastime, and often took the form, "if only he weren't President..."   How long before we decide that it's the system that's the problem? Then what?

III.

This isn't a case of unrealistic expectations.   These are expectations which deliberately ignore reality.   The Economist, in its post election article "Great Expectations," actually wrote:

Mr Obama will not take office until January 20th, but he can use the next ten weeks well. A good start would be to announce that he will offer jobs to a few Republicans.
Really? Could the writers of one of the most important periodicals actually believe this is a possibility? There had to be deep back room deals just to get Clinton people on his team. Old guard Democrats follow him everywhere. Really, Republicans? But not just Republicans:

Mr Obama might even find a non-executive role for John McCain, with whom he agrees on many things...
This is slightly less probably than Obama appointing Daleks to his cabinet, but the crucial issue is whether The Economist understands that its Great Expectations for Obama are exactly the opposite of the great expectations of a lot of the people who voted for him?

People voted for Bush for a variety of reasons, but any two Bush supporters, while differeing in what they wanted him to do, did not have a different expectation of what Bush would try to do. When Bush said he was going to keep Guantanamo open, we expected him to try to keep Guantanamo open. He did not try to close Guantanamo-- and no one expected him to.

These aren't unrealistic expectations, they're both perfectly realistic. What they are, however, is incompatible.

IV.

Don't listen to opinion polls that say 78% approve of Obama: the hatred on the Right is already seething. They'll not admit it, they'll avoid the topic altogether except amongst themselves, in hushed tones, always looking over their shoulder, cognizant that they are surrounded by enemies.

If they hated Obama, it wouldn't matter. They don't hate Obama.

The day after the election, Elizabeth Wurtzel wrote an op-ed inthe WSJ-- let me repeat that, the WSJ-- which began, "I must admit, I cried. I'm not perfectly sure why, but of course I was overjoyed."

Well, if she's not sure why she cried, it's going to be hard for half the country that didn't vote for him to know either. But I'll grant that the author of Prozac Nation may indeed have been so moved. "America itself," she writes, "which is a menagerie of mutts, has been a mightier nation for its diversity."

All fine sentiments which can be used to pad any college essay. The problem for her, for the WSJ, and for all of us, is that the sentence she wrote immediately preceding that one is this:

Most of the multiracial people I know seem more beautiful and talented than those of us boring folks who are just one dull thing.
When you write that in the WSJ, when you expect people to understand it, to agree with it-- when you ask people not simply to accept all races and cultures but to tacitly admit that yours is inferior, you are courting disaster.

They don't hate Obama, they hate Obama supporters.

V.

When a person heaps expectations and impulses on a person they don't really know well, in psychiatry it is called transference. When multiply diverse groups heap contradictory expectations and impulses on a person they don't know well, that's celebrity. They're the same process.

Obama's a celebrity, all right, I wonder if anyone has considered that this is not an entirely desirable role for a President. America has a love-hate relationship with all their other celebrities, why should this one end differently? Bill Clinton was the last celebrity President, a tenth of Obama, and you know what they did with him. And then they traded him for George Bush.

"But the celebrity's an accident, he didn't deliberately set out to become one."

I'm not so sure.   In this culture being a celebrity counts for a lot, as long as you are a celebrity we are willing to tolerate all sorts of nonsense, from nightvision sex tapes to Scientology to adopting 19 kids. We may even ultimately hate you, but if you say, "buy this," we do-- and on credit, of course. Celebrity and consumption are two sides of the same coin, and neither should be the purview of a President. Even if he didn't ask for celebrity, by accepting it he is following a dangerous narrative, one that allows the inclusion of this sentence in Entertainment Weekly, delivered with no irony whatsoever:

...but Obama was speaking to voters in a visual language they totally got: the celebrity-saturated shorthand of 21st-century consumerism.

Right. Here's $10. Keep the Change.

Left of left magazine Mother Jones attempted to make a similar point in "The Audacity of Hype?" the idea being that his hype is overwhelming (and detrimental.) But other progressives would not tolerate such questioning from their own ranks, despite the fact that both sides really were arguing that there was more to Obama than just hype. (1)

I'll admit that hype doesn't automatically mean there's no substance at all; it means that there is so much commotion it's hard to see what that substance is.

But it's hard to make the case that Obama isn't hype when his own supporters-- I think I can safely assume Entertainment Weekly counts among them-- try their best to make him into hype. This is a distraction; the result is that you don't know who he really is, and you are inevitably surprised when you find out.

VI.

I can see that the celebrity is a type of celebration, but there are consequences: it drives the 40% that didn't vote for him completely bananas. I don't mean "I hate the monkey fascist George Bush" bananas, either. People will disagree with me on this, but they're wrong-- this hype is more divisive than nearly anything George Bush has done.

Much of what Bush did conveyed the perception that he didn't care about your opinon, he answered only to himself and rubbed your nose in it. That made a lot of people hate him. The problem with these Obama covers and articles is that it is a whole half a nation saying, "in your face!" which makes people hate them.

Remember the flap about The New Yorker cover that showed Barack and Michelle in Taliban garb, doing the fist bump? That was irony, and it still made some liberals angry. But when you make this cover, with no irony at all

it makes people hate the people who voted for Obama. And if you do not believe this, then you are the one they hate.

VI.

The other problem with celebrity is it works only because it is lots of things to lots of people; it's rare to find a celebrity who is something all the time; those static celebrities we tire of quickly. Celebrity requires constant reinvention of oneself-- that's why most celebrities are actors or musicians. And yet, a constant refrain from exasperated celebrities: "but that's not really me!" Well, what did you expect when you posed for Entertainment Weekly?

It is still astonishing that a country with out history of slavery could elect a biracial man who identifies himself as African-American.

Unlike Ms. Wurtzel, I'm not going to pretend to know what Obama is or is not; but I think it's axiomatic that how you choose to identify yourself has little to do with it. Things are, or things are not.

But not for so many who want him to be so many things. Unfortunately for them, eventually he'll have to be himself, and whatever that is, people will be surprised by it. And won't like it. Honeymoon's over: here's me pooping.

I earlier wondered how an Obama Presidency would alter race relations in the country, perhaps away from race as the dividing characteristic and towards class. I think I was wrong. That was an outrageously optimistic prediction made because I bought into the hype. What happens as unrealistic expectations are dashed?

Here's a prediction for you, put it in your calendar: within one year, people will be saying Obama isn't really black. Here, Leno, I'll even write the joke for you: "... American's first and only black President, Bill Clinton." Call me.

VII.

The hyping of the Obamyth has consequences for the next election as well. Republicans are likely to come out to vote in droves-- think Newt Gingrich in 1994. Liberals, if disappointed, probably won't vote Republican-- they're simply not going to vote at all. That means a Republican win by a larger margin.

If we're lucky, it'll play out calmly. But the divisiveness of the Celebration of The Obamyth is not to be underestimated, it is making a lot of people very angry, a lot of people who you hear almost nothing about at all-- it's as if they don't exist. But they're there, the new disenfranchised, even if Time Magazine tells you they aren't. They won't take up arms, surely, but neither do bees, and it's still probably best not to taunt them.

Meanwhile, the contradictory expectations of so many of his supporters will inevitably result in some groups feeling duped. Not disappointed. Duped. At minimum they pull away from the political process, at maximum they riot.

That seems unlikely to you? America's too big to fail? Spain had to put down some violent protests just last week. France is "a social bomb waiting to explode." And Greece was on fire a month ago. Are these third world puppet states?

It would be a mistake to think these riots happened because their leaders didn't get them what they wanted. That's only what made them angry. They became violent because they believed the system-- not Sarkozy or Zapatero or George W. Bush, but the system-- was not listening to them. If the already disenfranchised whom Obama collected under his umbrella later feel spurned or tricked-- look out.

Obama reportedly hopes to fashion himself after Abraham Lincoln. It would be worthwhile to emphasize that Lincoln's great accomplishment was not freeing the slaves or the Homestead Act but doing whatever it took to keep the republic together, at any cost-- even if it compromised some of his own particular beliefs.

Please, Mr. Obama, now that you've won the election, take my advice. If you get invited to the Oscars, politely decline. And if Vanity Fair wants to put you on the cover, the correct answer is no.

---------------------------

The other post: The Wrong Lessons Of Iraq

1. Ahh, but isn't Mother Jones really playing the meta card, sending a Manchurian Candidtate propaganda to Rush Limbaugh and his ilk: "we, the leftie communists at MoJo, aren't really happy with this fake progressive, he's not really that progressive..." making him more palatable to the right?--- Who knows? But doesn't that just support the contention that no one even cares what Obama is, just what he can be identified as?)

===== ====== ===== The Last Psychiatrist: Wrong About Obama II

the sound you just heard is millions of teeth grinding at once

In retrospect an easy call to make; at the time considered sour grapes: a year after the election of the Messiah, the country would instead be more angry and hateful than ever. Not the Change he planned, but you get what you pay for.

The prediction was specific: not that Obama would ruin us, though he might; or that we were marching towards mercantilism, though we were.

Instead, the prediction was really an observation about Messiahs: no one hates Christ or Mohammed, they hate Christians and Muslims.

II.

"No one is saying what Joe Stack did was right. But you have to understand the anger, the resentment, there's a lot of people who feel like they're just being pushed around. Joe Stack is a sort of a symbol..."

Would anyone listen if I pointed out that these are the same words that we hated to hear about the 9-11 hijackers or Palestinian suicide bombers?

But anyway, why do you need a symbol, why do you need him as your symbol? You're angry that the government is creating a welfare state, with your tax money, that collars poor Americans into service and obedience.    Jeffersonians were in opposition to Hamiltonians (and Lagrangians) not just on the principle of government authority-- Hamilton wanting a strong central power to govern for the benefit of the people-- but also on consequences: strong government meant big increases in public services and public debt, which in turn reinforces the reliance on an ever expanding government. Sound familiar? So what do you need Joe Stack for?

Maybe because Joe Stack isn't a symbol for the expansion of the welfare state at the expense of individual freedoms, or somehing; maybe he's just a symbol of an angry man who's not really sure why he's angry, he just knows someone else is to blame. In which case he's the perfect symbol.

You don't need a symbol to say, "taxes are way too high." You need a symbol to say, "this is who I am."

III.

James Surowiecki, the writer at The New Yorker without encephalitis, wote:

Whereas the economic populism of the 1890s and the right wing cultural populism of recent years represented reasonably coherent ideologies, this new populism has stitched together incompatible concerns and goals into one "I'm mad as hell" quilt. The people may have spoken. It's just not clear that they're making any sense.

Obama hasn't closed Guantanamo-- and he won't. He hasn't brought the troops home from Iraq; and he won't. He's increased those in Afghanistan, saying he'll bring them back in 18 months. He won't. He hasn't reduced the opacity of the government, the Patriot Act just got an extension. But if you were for those things under Bush, why aren't you relieved about those now? If you were against them under Bush, why aren't you mad now?

The primary thing isn't what you are angry about, the primary thing is your anger.

IV.

This is an example. After the election-- and anyone who didn't vote for Obama will know exactly what I'm talking about-- you didn't dare say a negative thing about Obama in public. Certainly not a flippant slander, the kind that are common when discussing Presidents. If you were in a restaurant, before you said anything about Obama you took a serious look around to see who else was near you, and only if it was safe (read: white) could you quickly whisper some veiled comment. You weren't even allowed to be pessimistic about Obama. That was the climate. Again, if you didn't vote for Obama you will know what I mean, if you did you'll think I'm exaggerating. I'm not. Talking negatively about Obama in public was like trying to tell a dirty joke down at Human Resources.

Fast forward to last week. This is what I heard a guy announce in a crowded downtown restaurant, and I'm quoting:

Fuck him. Fuck Obama, fuck him, and fuck his horsefaced wife. I'm sick of his shit.

Agree/disagree if you want, but understand that that guy's anger had nothing to do with Obama at all. That guy wasn't voicing his opinion, he was looking for a fight. He was daring someone to say something. He wasn't saying this loudly despite his better judgment, he was saying it on purpose. He was throwing the guantlet down, cognitive kill switch style. "Oh, I can't criticize Obama? I can't say anything because it means I'm a racist? Well fuck you too." That guy did not have an airplane, but if he did I am certain he would have flown it into his sandwich.

This is the point: that man doesn't hate Obama, he hates Obama supporters.

V.

This is what the Angry Joe thinks people thought in Nov 2008:

Red: "I guess McCain. What other choice do I have?"

Blue: "Go Obama! Ha! Who's laughing now, bitches! Take that! I hope he raises taxes to 500%, I hope he rapes your daughters. Time to redistribute the income, all to me! Payback time! You mother---"

Unfortunately, his crazy paranoic delusion is validated by ten seconds of any episode of the Rachel Maddow show.

VI.

In case you have had a short life or memory, Obama isn't the most hated modern President. In terms of depth of hatred, Reagan beats them all, even Nixon. Openly considered a monster, evil, he was going to bring us to nuclear war on purpose just to kill minorities and then he'd forget all about it because he had taken a nap. The band Genesis made a video with him doing pretty much that, and it won awards. Imagine if a pop band did that with Obama.

However, the hatred was confined to Reagan, not to everyone who liked Reagan. No one got cut off in traffic and thought, "look at this jerk, I'll bet he voted for Reagan." But now...

This is probably because of the way we're now trained to discuss politics: me vs. you. We are encouraged to make the focus be the argument, not the content. Setting yourself in opposition to someone who appears to have a definable character is a shortcut to your own branding, which is why you're having the argument.

VII.

The problem with getting the President you want, only to find that he not only doesn't deliver on his campaign promises, but he's quite uninterested in delivering many of them, is that you don't blame him, you blame the government.

We've become what we dread most: France. A strong central government that everyone throughout the spectrum hates. Now what? Can't punch a government, but you can kill an entirely uninvolved IRS agent with an airplane. Score one for freedom.

"The country is ungovernable, we need a reform of government!" Why is it more ungovernable now? The government is the same one we've had for 2 generations. Nancy Pelosi, Harry Reid, Mitch McConnell, Dick Durbin-- all your major players from both sides-- have been there for over 20 years. Ideas and ideology haven't changed since Vietnam. Obama was the Change guy-- but there aren't any new ideas there. Hell, he's even copying Bush.

The deep, strong cry of all civilized nations, -- a cry which, every one now sees, must and will be answered, is: Give us a reform of Government! A good structure of legislation, a proper check upon the executive, a wise arrangement of the judiciary, is all that is wanting for human happiness...
If only!

Were the laws, the government, in good order, all were well with us; the rest would care for itself! Dissentients from this opinion, expressed or implied, are now rarely to be met with; widely and angrily as men differ in its application, the principle is admitted by all.

Just like then, it's nigh impossible to find anyone who doesn't think this is true. A complete turnover of Congress would be awesome, I'll admit, but don't think for a second that anything can change just because you change your representatives. The problem isn't the government, the problem is you. It is always you.

VIII.

You can't imagine how you, one guy, can be the problem-- the government is much bigger than you, isn't it? But there are millions of people exactly like you. One byproduct of modern narcissism's reliance on finite media is that countless other people are modeling their lives on the same template you are. You think you are unique in your thoughts and identity, turns out you are a clone. You think you're the only guy for whom X was transformative? The only guy with an iphone?

Most of you are huddled around the same directors feeding you the same lines which you regurgitate with sufficient passion you think you came up with it. I'll bet you're sure that "tax and spend Democrats like Nancy Pelosi and Harry Reid are running this country," or that we need "renewable sources of energy that will also help create new jobs"-- all of which might even be true except that the exact same contentless words are being thought by millions of other people who are all sure they know it. That doesn't make you pause?

It would be awesome, awesome, if these sound bites were being fed to you with an intent to deceive- as part of a Hearstian conspiracy to make the cattle think one thing so the Elites could do another; in short, awesome if, after all, there was some organized effort leading to a clear goal, no matter how nefarious. But there isn't. It's a battle royal, every man and company and politician fighting to eat and not be eaten. Even families operate at cross purposes, kids trying to leave, parents holding on to nothing, everyone looking for a "moment to myself." This isn't a war of ideals, it's cannibalism.

IX.

Are you teaching your kids that certain people-- the government-- oppose your values? Why would you teach them that? By all means teach them your values, but don't communicate it as a battle against other people. You're turning your kids into you.

X.

You get the politicians you deserve. Arguing over "cutting spending" polarizes Americans because that soundbite is contentless, but elicits a strong emotional response not to a plan but about an imagined recipient (welfare abusers, etc.) This kind of a debate is an addictive drug.

Politicians will give you what you want. If you say you're for "cutting spending" then they'll be for "cutting spending." That's all. If you want them to actually cut spending, you have to tell them what spending you actually want cut. They're representatives, not leaders, right?

Senator Bunning didn't understand this. He thought Americans actually wanted spending cut, so he actually blocked the extension of unemployment benefits. Man, what a square. Well, he's only been around for a term and a half. Chalk it up to inexperience.

XI.

Required reading for anyone unclear about the stakes is Ferguson's Complexity and Collapse subtitled in the print edition, When The American Empire Goes, It Is Likely To Go Quickly. But for those who are used to getting their political theory from aviation experts or the people who discuss them, here's the most important line:

Neither interest rates at zero nor fiscal stimulus can achieve a sustainable recovery if people in the United States and abroad collectively decide, overnight, that such measures will lead to much higher inflation rates or outright default... such decisions are self fulfilling. (italics mine, emphasis ours.)
You can't change the government because you don't even know what you want from it. You have to reconfigure your own mind. Your current expectations of life aren't just unrealistic, they're not even what you want. Another byproduct of narcissism is when you model yourself on a template, you'll pursue the goals of the template. You're chasing someone else's happiness.

I don't think we're on the verge of collapse, but I can predict that unless we turn away from empty political discourse, we are in for more airplanes.

---

http://twitter.com/thelastpsych

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===== ====== ===== The Last Psychiatrist: Xanax, Vicodin, Percocet, Ritalin and Valium

When patients complain about doctors, it's usually about overcharging and undercaring. When doctors complain about doctors, however, it's usually about those with "loose" practice, especially in the inner cities , who seem to overprescribe Xanax and Percocet.
But let's ask a different question: what would happen if all of these doctors disappeared? If there was no fast and easy way to get prescribed legal Xanax, would all the Xanax seekers just disappear?
In large part, many psychiatrists and primary docs have the luxury of proclaiming that they "don't give out Xanax and Percocet" because there is somewhere else for those patients to go. Dr. Smith from University Clinic doesn't have to haggle over #10 Percocets because the patients can go to other doctors who are much more-- comfortable, let's say-- giving out #90 Percocets a month.

I was trying to think of an analogy. Black market jumped to mind, but these items aren't illegal nor illegally obtained. Surprisingly, the best analogy I found was illegal immigration.

In this case, illegals supply a required function that the existing distribution of the laborforce does not satisfy. Without that supply of illegals, the very existence of the industries that use them would be threatened. There would not be as many restaurants, or as many different kinds. And costs would be reduced elsewhere, maybe in unsafe ways. Additionally, like illegal immigration (and black market economies), the situation exists in the open-- precisely because of its necessity.
So if the "loose" Percocet prescribers disappeared, two things would happen: first, Percocet would be pushed into the ilicit underground trade. It is already partly there. It would become more abused with the removal of even the rudimentary medical supervision. Second, the practice of medicine itself would change drastically. It's easy to say that low back pain should only be treated with NSAIDs or physical therapy and weight loss, but it's easy only because the the 100 million scripts a year for Percocet are being written by people who don't say that. It's also easy to be dogmatic that SSRIs should be the first line agents for the treatment of anxiety as long as you're willing to purposely ignore the 50 million combined yearly scripts for Xanax and Klonopin that non-academics are writing. (For reference: Lipitor is 63 million.)
These commonly maligned inner city doctors actually serve as a pressure valve on the rest of medicine, in the same way that illegal immigration is a pressure valve on labor and industry.
I'm not judging the actual clinical utility of these drugs, nor am I saying that "loose" practice is good or bad. I am thinking about what role, if any, such practice has in the larger scheme of medicine. And I'm convinced that it's actually quite enormous.
What proportion of the inner city population, for example, goes for routine preventative medical care-- checkups,, blood draws, etc-- only because that doctor also gives them Percocet for back pain? How many people fill the Glucophage only because there's a Percocet on the same script? I have no idea-- is it 15%? If it is, is it ethical, by " not prescribing narcotics," to create circumstances in which patients self-select inferior medical care?
Let's assume Dr. Smith is one of the best doctors in America and he has unparalleled success at treating diabetes in his patients. However, he never gives Percocet or other narcotics: "that's my policy." Patients looking for Percocet-- for abuse or legitimate purposes-- will not go to him, and consequently get inferior diabetes care. Is this ethical?
I'm not saying that the Dr. Percocet won't give good care; I think you understand that my point is how seemingly unrelated medical decisions may in fact be the key medical decisions.

From a simple patient advocacy perspective, I think it's possibly both disingenuous and unfair to have a "policy" on narcotics. Whether the risks outweigh the benefits isn't something that can be answered a priori-- each patient's situation is different. So saying "I don't give Xanax" willfully ignores the uniqueness of each patient's existence, as well as the clinical data that says the thing actually does work.
Treating the patient with maxims and guidelines that result in the patient leaving treatment to go elsewhere is, arguably, the opposite of medical care. Medical treatment often requires unorthodox and unproven maneuvers, but always with an eye towards the risks and benefits, and to the single goal of improving the patient's condition.
I don't have all the answers, but I have a lot more questions.

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===== ====== ===== The Last Psychiatrist: Yeah, Well, Cry Me A River
If you're watching it, it's for you.

I can assume everyone has seen the clip of Susan Boyle singing I Dream A Dream on Britain's Got Talent.

"Your halo is a little two steps to the right."

Everyone loves an underdog. Everyone loves a high horse, too: "take that, you prejudicial prigs, who expect a good voice to only come out of slinky blondes with belly rings."

Myself, I don't expect it only out of slinky blondes, though I'll admit I like it better. But despite my fascination with slinky blondes, I have never bothered to find one that sang on Youtube. My lust cannot be monetized.

I did, however, against all better judgment, go look for this clip. And there's the rub.

Let's step back and ask some questions:

Is it really surprising to anyone that a 47 year old woman can have a great voice? (Opera, Aretha Franklin, etc?)
Is it surprising to anyone that an overweight or homely woman can have a great voice? (Madonna, Coldplay, etc? (Zing!))

No. Which brings me to the 3rd question:

3. Could it possibly be surprising to Simon Cowell? After seven years of Britain's Got 10p Text Messaging, he was suddenly caught off guard?

That I smell a rat is besides the point. My first instinct is that Simon had already heard her sing, or maybe even specifically recruited her to come for an audition because of her 1999 single Cry Me A River.

This doesn't take away from her ability-- she can sing a tune, that's for damn sure.

But what's relevant point here is what is being done to you. Regardless of whether Simon knew about her beforehand, her performance has now been packaged and marketed in a different way, specifically for you, based on what they know you like. This further reinforces those preferences on your part. In other words, they are giving you what you want, and training you to want the next thing.

Watch the clip, the editing, the story they are writing: how they contrast from shots of cynical audience members, then cut back and forth to the hosts and audience as they look on in amazement. That's all done after the fact. That's the performance. The live studio audience is legitimately impressed as it happens; but the Youtube viewers are compelled to be impressed by the slick Hollywood movie they are watching.    If you had stumbled upon a clip of her singing into a webcam in her kitchen, you might say, "wow, whaddya know" and then gone back to porn or stock quotes. But when you are told "go see this (highly produced) clip" then you believe they hype. It's putting a $100 price tag on a bottle of wine, and therefore liking it more.

Britain's Got Talent isn't trying to eventually find the next winner so they can give them a record deal; it's trying to get viewers now, ad revenue, and text messages. You don't do that with another slinky blonde-- to sell records yes; but to get TV viewers no-- you do it with someone who is going to appeal to the show's demographic.

What you want is a shot of Simon-- the eye candy for the target demographic-- looking dreamy eyed.

"I said, 'my darling, you look wonderful to-night.'"

It's not a talent show, it's a docudrama.

Let's peek at the meta-script's next act. Boyle's awesome, but where's the drama? Who is going to be her nemesis on the show? You might first consider a slinky blonde-- but that wouldn't work because it's not polarizing, there's no tug of war. You want someone who pulls at the same viewer who likes Boyle, but in a different way, to create inner tension.

In other words, you want a cute kid.

And look, he wore a tie!

A 20 year old wants to love someone who ultimately wins and hate someone who eventually loses. A 40 year old wants to love two people, and be sad when it ends for one of them.

Part of this, as one clever reader emailed me, is that Boyle's story fits the theme of my favorite generation: even at 47, you could still possibly have your life activated and assume your rightful place in your movie. Not through hard work or perseverance, of course, but simply by being discovered.

"But hold on-- she did work hard to be able to sing that well!"

Sure-- but notice that's not part of this story that they are telling you. They deliberately emphasize her backwards, never been kissed, works in a diner persona. "Oh, I've just sung in my church choir." Really? Is that all?

She can be the undiscovered, "am I too old?" neglected talent; the kid can be the budding prodigy, "even if you lose kid, you're going to be a winner."

Undiscovered is the new porn.

To repeat: none of this detracts from Boyle's excellent voice, or her chance to make from this what she can. But do not think the gods smiled on Susan Boyle and, lo, she has been discovered.

Susan Boyle, plant or not, is a character in a well scripted movie, with the only theme that will get people to sit in front of the telly nowadays: everyone's a winner, unless they're a loser, and then they're winners, too. And 47 is no longer too late. Everything you see from now on will have been carefully scripted and choreographed.

Everything, that is, except the unfortunate crash that always seems to come at the end of these dramas. When everyone has to go back to real life.

And by everyone, I mean you.

===== ====== ===== The Last Psychiatrist: Yet Another Study On Antidepressants, And No One Notices The Timing
Are we on this again?

"Study doubts the effectiveness of antidepressant drugs." Or, even better, as per The Independent: "Antidepressant drugs don't work-- official study."

I don't know what passes for official nowadays. The data is the exact same data that has existed for 30 years. Yes, these authors are acting like they FOIA-ed the second Zapruder film, but let me assure you it's the same old data. These authors did the exact same study in 2002. So have twenty other groups. This is not new.

But it is news. The question is why.

1. I have a side question. Why is it that when an article says something works, people are suspicious of bias, but when an article says something doesn't work, everyone thinks it's objective science?   IT'S ALL BIAS.

2. People are completely missing the point of this paper and all the other recent re-investigations, the true social and clinical consequences of them. For example: they're saying antidepressants are no good. Ok. What do you think doctors are going to use instead? Psychoanalysis? Nothing? They're going to prescribe antipsychotics. Are you listening to me? I'm not even saying this is clinically wrong to do, but do you not see the setup? Abre los ojos, man.

3. Previously, when SSRIs were being shown to be super effective, people suspected Pharma bias. Now they are being shown to be ineffective, and people fail to see the bias. IT'S THE EXACT SAME BIAS- Pharma. That's why there are popular press stories on this now, as opposed to five years ago. GSK doesn't care that Paxil is ineffective. Do you know why? Because they want you on Lamictal. (Again, this isn't to diminish Lamictal's or antipsychotics' usefulness. I'm just talking politics.)

4. And the handmaiden of Pharma is the academic. You can't make a career studying generic medicines, because no one but the NIH will fund you to do it. And nowhere save Hollywood is there more cronyism and prejudice than at the NIH, so just forget it. You're an academic looking to cover your salary? Get promoted? The address on your grant application better read "Bristol Myers, Makers Of Awesome Abilify." If it says "Bethesda Maryland," slit your wrists now.

5. The study does not say that antidepressants don't work; it says that they don't work better than placebo. Placebo is not nothing. The question someone should be asking is how the hell placebo generates 35% improvement in all but the most severely depressed.

5b. ...And why the placebo works worse in the severely depressed. Before you jump to the obvious answer, note that antidepressants had similar efficacy, independent of severity.

6. If the drug had been no better than placebo, but placebo had only 2% efficacy, then yes, the drug would be worthless. See the difference?

6b. But that isn't true, either. If any of the structural classists over at The Independent would care to explain how failure in Major Depressive Disorder can be extrapolated to OCD, panic, multiple myeloma, etc, I'm listening. "Mexicans don't work-- official study."

6c. "Why did you add multiple myeloma? How's that? It's an antidepressant, a psych drug." No, it's called an antidepressant, it's used by psychiatrists. You have no way of knowing what it actually is. Look at the history of thalidomide. "Girls named Candi are sluts-- official study."   While I'll agree that any parents who name their kid Candi are probably at risk for having a brass pole set up in the basement, you can't make any judgments about Candi herself based on her name. Do you know why? Because she didn't get to name herself.

There's a lot we can learn from the recent controversies surrounding antidepressants, and by a lot I mean only one thing, best articulated by Lewis Black: "Doctors don't know. They pretend to know. Because they have a rectal thermometer in their pocket. As if it was an appeal to a higher authority."

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===== ====== ===== The Last Psychiatrist: You Always Know Less Than Your Source, Unless It's Balenciaga
The Pew Research Center asked 3612 adults three questions:

Which party controls the U.S. House of Representative?
Who is the Secretary of State?
Who is the Prime Minister of Great Britain?
And they found something interesting that they did not report.

I.

18% got all three questions right; only 30% knew Gordon Brown; 50% knew "Democrats" and 42% knew "Condoleeza Rice."

But the scores according to the audience of specific news sources:

A few observations: The New Yorker readers are college educated and older, while The Daily Show people are still in college. perhaps affecting the results. However only 31% of Hannity & Colmes viewers are college graduates, and they scored well. So education itself is not the explanation.

Obviously, certain shows beat you over the head with the information. That's all Rush and the Colbert Report talk about; but they don't much mention Great Britain. So those scores of those audiences make sense.

What doesn't makes sense-- or, unfortunately, makes too much sense-- is why CNN viewers did worse than everyone. If CNN is objective news, all the time, what happened?

II.

Using Lexis-Nexis, I learned that in the past month, NPR has done 14 stories containing the search words "Gordon Brown." Fox News did 10. CNN had 24. "Gordon Brown" appears zero times in The New Yorker. Clearly, there are multiple factors that go into why certain people are more knowledgeable than others, but that still leaves open the question why those who are news watchers know less?

Why were BBC watchers no more informed on Gordon Brown than Rush's listeners? Remember, these are Americans who chose to watch the BBC. I'm sure it's the same nuts who always tell me, "the BBC is so much better than our news."

It's high school-- they drilled the info into you, but it never "took." What NPR and The New Yorker and even The Daily Show do is present the information in a context (e.g. here's why Bush sucks; here's a funny setup) that is usable by the audience ("hey, here's why Bush sucks;" "dude, this is hilarious, Gordon Brown...") That's a good way of making it stick, and it helps explain why CNN's info doesn't stick, but it means the message is now inseparable from the media. And this is more dangerous, because you think you possess knowledge that you do not actually possess.

Here's an example, arbitrarily using Rush Limbaugh. Say he is talking about something you don't know much about, like the difference between the American and British responses to the banking crisis. He actually explains well very complex information and the possible consequences. You absolutely know more than you did before you heard him, even if you disagree with his conclusions.

But if someone asks you a question about this info, your response is most likely a version of what Rush said. But worse, you don't realize this-- you think you are intelligently coming up with the info yourself. You are not aware that you are reading from someone else's script.

This conceit of knowledge almost always results form learning from one source-- because it is never tested by a contrasting opinion.

III.

Balenciaga is one of the oldest (i.e. from the 1960s) French fashion houses, but it has stopped producing haut couture because, simply, it wasn't profitable. They've turned to ready-to-wear clothes, which are still elaborate, still have complex cuts and folds, seams, still are expensive, and still are French. It may be "off the rack," but it's still Balenciaga, and anyone who knows anything will recognize it.

But there's a willful denial in play. The trick is claiming that you have your own unique style, yet that style is available to anyone who chooses to buy it; you had nothing at all to do with it. I suppose it's possible to claim you're different than those Givenchy sluts, but it is merely a fantasy-- or delusion-- that your style is entirely yours-- or even barely yours.

Even a woman who buys from a thrift store puts more original thought into her wardrobe, though of course even her style is bound by someone else's sketches so many years ago.

But try telling any woman in a designer dress that, and she'll punch you right in the nose. "Yes, someone else had the idea for this dress, and created it; but it perfectly expresses who I am. It is, for all intents and purposes, my ideas for clothes. Of what consequence to me is it that 5000 other women feel the same way? I still look amazing."

IV.

So the fact that The New Yorker readers and Rush Limbaugh listeners possess a lot of information speaks to the contextualization, the usability of their presentation of that info, and how much it resonates with the particular inclinations of the audience. Unfortunately, it's hard to know more info than your source for that info, and if you only have one source... you don't know very much.

But ignorance-- socratic ignorance, you-know-you-don't-know ignorance, is hardly the worst thing that can happen. No, the worst thing, in a democracy, is to think the thoughts someone else gave you-- gave 5000 other people-- prete a porter, and believe they are your own.

===== ====== ===== The Last Psychiatrist: You Are The 98%

no, they forced you

"We are the 99%."

Rarely does a slogan perfectly capture the zeitgeist, the ethos and the pathos, each word a passionate announcement of a popular uprising. And neither does this one.

It is, however, an important piece of propaganda. It sounds like the enemy is Wall Street, but observe that the slogan doesn't point to an enemy, it defines the group. The slogan is a twist on an old fascist standby: select a minority enemy, and create an impression of opposing unanimity. Once done, the leaders of the group have the powerbase to do what they want, making it impossible for anyone in the rest of the 98% to disavow this madness. When it all goes down you will be too terrified, or too busy, to dissent.

Take a look at the website, see which one you are.

I very, very much empathize with this woman, but her aside, what if I don't believe education is they key? What if I think there should be no such thing as student loans at all? What if I think that it, not Wall Street, is a far greater enemy of civilization?   Do I get to be in the 99%? Do I get a choice?

Here are some of the demands of #OccupyWallStreet:

Restoration of the living wage.
Free college education
Begin a fast track process to bring the fossil fuel economy to an end
One trillion dollars in infrastructure
Open borders migration

Never mind that these demands are internally inconsistent, mathematically impossible and downright weird. ("Bank to Bank Debt and all Bonds and Margin Call Debt in the stock market including all Derivatives or Credit Default Swaps, all 65 trillion dollars of them must also be stricken from the "Books."" Really? You want that?) What's important is that most of the 99% don't want all those things, or even most of those things.

Grant me that when Naomi Klein is invited to speak for the 99%, at least 45% are looking at each other like, wtf, who let Linda Tripp in here?

Do you think that when the movement becomes powerful they will represent the guy making $533000 as well as the guy making $0? How about the $250k and the $5k? All the way to the median income of $30k, but-- surprise-- that $30k guy most definitely does not want anything to do with an open border policy and guaranteed living wage and abolition of the death penalty. Oh, your plan is to exclude all of the states that have >2 right angle borders. Hmm.

They exist in a quantum superposition of multiple eigenstates, but the moment they make an official demand the whole thing will collapse into a single state and everyone will hate it.

Which is why any demands are quickly disavowed, "There is NO official list of demands," they emphasize on the site, and yet the point isn't the demands, the point is the "they." The point is to pretend that there aren't any official demands, attract the largest possible base-- who doesn't hate Wall Street?-- and then make demands. "'They?' You mean the loose affiliation of Trader Joe's shoppers at OccupyWallSt?" No, I mean the guys who can say this:

This content was not published by the OccupyWallSt.org collective, nor was it ever proposed or agreed to on a consensus basis with the NYC General Assembly.

They say they have no leader which means it's pointless. If they do get a leader, science suggests it will naturally be a man with a long ring finger and some psychopathic traits; all I know is that they will simultaneously count me amongst their numbers even as they ask me please to die. Or kill, depending on how much power they get.

II.

What you don't realize about those pictured as "the 99%"--what they have in common is not that they are young or college educated or indebted or white females, but that they were willing to put a picture of themselves on the internet, fully of the belief that they stand for something worth being pictured for. Bad move.

You think marching on Wall Street gives you power, a voice; but it is a wholesale surrender to the media, you have signed a waiver allowing them to use your image any way they want, and they will tell the rest of us what to think of you and titrate our exposure and emotional responses, all while feeding us with marketing for the very things that got us into our predicament. The income disparities, the education pyramid scheme, the personal and public debt, the anxiety, brought to you by Revlon and the makers of CNN.

Take a guess which side Fox, MSNBC, John Stewart chose. How did you know? Wrong: it isn't their "bias" because it doesn't matter what the protestors want, it's because they predictably transmorph the protestors into what they need them to be.

"Marching gets our message out." No it doesn't, it gets CNN's message out. "We don't watch CNN, we use the internet." Yet given the infinity of the internet you still surf the same 5 websites, looking for and finding exactly what you want, like a baby playing peekaboo in a mirror over and over and over and over and over and over and...

You are the 98%, you are totally without any access to the machinery of power and worse, much worse, you plug yourselves into the machinery of media and become a slave.

"That's why I don't watch television!" Well, a) you mean TV dramas, and 2) it's because you're not a 45 year old woman, the target demo of TV. But maybe you're proud that you skip the commercials and avoid the "mainstream media", you don't want to be part of the corporate consumerist machine and good for you, yet your independence is why Whole Foods knows you'll buy anything wrapped in brown and you already have a subscription to The New Yorker, which has a curiously large number of ads for mental institutions. If you're reading it, it's for you. The New Yorker is also at the checkout counter in Whole Foods, along with Rolling Stone and Psychology Today and not along with Sports Illustrated and The Weekly Standard. You think you shop at Whole Foods because it has better quality food? It's because of those magazines.   Even the neocons who shop there-- they don't shop at Acme-- shop there because of the branding: liberal=organic, so the more left wing magazines and the more dred locks the more it has reinforced the "liberalism" and therefore the "quality," and so you go, "reluctantly", shaking your head at the crazy commies stocking the store as you hand them 3x more than anything is worth. "Would you like to donate $1 to help Ethiopian refugees?" Son of a bitch, this apple is delicious.

III.

If you hold a protest and you aren't throwing rocks it will fail. I'm not telling you to throw rocks, I'm explaining why your march won't work.

The reason "peaceful protests" don't work anymore is because now the protests are slower than the media coverage. When they threw the tea in Boston Harbor it was urgent, immediate, and by the time the press could interpret it it had already been digested by the public.   But now even before the protest reaches critical mass the media, whose agents outnumber the protestors 100 to 1, has packaged and produced it, like a reality show, and by the time Naomi Klein got there I had already been told to expect someone like her. Do you see? She had already appeared before she got there. Yes, I can take pride in thinking for myself but if I'm going to be honest, all I'm doing is reacting to what I'm told. I was once going to write something about what Amanda Knox's innocence revealed about our earlier media prejudices, and then I realized I still have no idea if she's innocent or guilty, only that the media tells me she isn't. And then I wondered, why do I even care if she is guilty or innocent, why do I even know her name, what's that got to do with me? Because the media decide not just truth and falsehood but existence and non-existence. #OccupyWallStreet never stood a chance, come one person, come ten million people, it doesn't matter, the only people who have any power are people like her:

and she is stronger than all of you. Close your eyes: do you remember anyone else?

You can agree or disagree, but you must do it with her, not with the folks holding signs. And by her I don't mean her, of course, she doesn't get to decide what she thinks, either-- her producer tells her, and so on up the chain.

Late at night as I'm drinking my eyes blind I hear the protesters regularly complain that they are not getting enough media coverage. They are protesting Wall Street, and they want more Wall Street coverage? You lose.

Those protesters are based in a world that is built on rules. Because of this, they will never be as strong, or as fast, as the media that exists outside those rules. "Hey, stupid, what's that? a sign? TOO SLOW, we have a thousand satellites and a harem of reporters, from beautiful blondes to ugly intellectuals, we control the whole thing. You even put a hashtag in your official name because your only voice is twitter. Bless my heart-- twitter! How absolutely precious. Don't forget to rock the vote!"

"We are the 99%. We want to cut the umbilical cord from fossil fuels and consumerism." Easy, but then what? There are two ends to that cord, something has to nourish you and all that's left since you can't afford what you were told you needed is the placenta of the political-media machine. "Get out the vote" is truly terrible advice, the only way to win is not to play. If you're at the protest and a guy comes around asking you to register and it's not for a handgun, punch him in the face. He's your enemy.

"We need a third party!" Come on, do you think the media will allow you to have a third party? John Anderson, Ross Perot, Ralph Nader-- they let them through to "show" third party candidates aren't any more serious than Howard Stern when he ran for governor. Poor Ron Paul pulls in more people than porn but he can't get a break, sorry buddy, 100 years too late for your kind. There's a difference between what you need and what you want, and the media will always, relentlessly give you what you want. Do you know why you have such poor candidates every single election? Because you want them, you want someone you can easily judge for some sexual indiscretion or because they called latinos chicanos. "Well, that matters to us!" Then you got what you asked for.

The media will have data mined the culture and chosen for you two cans of Campbell's Chicken Soup, and then encouraged a public debate about which can is a better representation of the spirit of the country, the one on the left or the one on the right. "Well, that matters to us!" I know.

IV.

The protests will fail. They will eventually be co-opted by the pre-election media orgasmia, branded as either this team or that and assigned a leader no one would have ever picked, ever, ever.    The Tea Party may have started with Rick Santelli but they soon got Sarah Palin, figure that out. Half of you will vote, all of you will complain, and nothing will change until the day we are buying fake iPads with real yuans, hey, who's the balding guy on the 20? And the 50? And the 100...? And the reason it will fail is that you don't want it to succeed. You are still holding on to the mercantilist, zero-sum economic delusion that tariffs and gold standards and less money for Wall Street means more money for you, and then you can go back to living like it's 1999 again. You can't. It's over.

Of course Wall Street has excessive profits, but just as your life has been an inflated delusion of easy credit, so has theirs; yes, they have received an obscene share of that fake money, and ten-twenty years ago maybe you could have redistributed that fake money, but that ship has sailed. Now, the moment you take it away from them it ceases to exist, poof, it's gone. It's fine if you want to do it to punish them, I get it, it's the right thing to do and Glass-Steagall and all that, but it won't help your situation one bit.

$3.6T out, $2.4T in, those are the numbers, and in case you want something on letterhead here's the CBO saying taxing the rich would get us $450B over ten years. Ten years! Double the taxes, triple the taxes, it makes no difference, it's over. The only way out is a massive tax on wealth; cold fusion; a war; a new media; or inflation. Inflation has the side benefit of pushing you into a higher tax bracket and we'll all get to see what a $1000 bill looks like.

"We are the 99%." Stop it. There is a 1%, fighting another 1%, and while both of those megalomaniancs dominate the media coverage the other 98% has no recourse, no representation, no allies, and no savings. If you're over forty 2007 was the best you will ever have it, make sure you backup your photos, it may not get worse than this but your only hope for growth is the next generation so you better change your expectations and your priorities. If you want to eat something other than canned goods and insects when you're 80 you better prepare your kids now, work them harder in math and get them to read better books, make some kind of/all kinds of a sacrifice for them, because the only thing keeping you from the hellacious Medicare funded nursing homes and the Social Security that will not exist is them, the 17 year olds you are screaming at for drinking too much of the whisky you are hiding in the bathroom.

And in 2030 don't tell me "the young should respect their elders," in the oldest of days the elderly were revered not because the young were respectful but because in those days if you made it to 60 you were a goddamn superhero. "Whatever the hell this guy did in his life," Johnny said to Timmy, "I'm copying. How in Sutekh's name did he not get eaten by a hyena?" If the hyenas had slacked off maybe those youth wouldn't have been so respectful. Pray you don't find out.

Are you listening to me? Or were you looking at the woman in the red dress?

You are the 98%, and you are too slow.

---

The Dumbest Economic Collapse In History

http://twitter.com/thelastpsych

===== ====== ===== The Last Psychiatrist: You Can Have Your License Revoked For That?
It's hard to see the truth when the truth is uninteresting, long, or contained in PDF. What's left is the interesting untruth, which then becomes truth.

And then we all have a big problem.

Close to home (and to the area almost completely responsible for the housing collapse) comes the case of Dr. Edward Sanders who, according to the Marin Independent Journal, had his license revoked because, among other reasons:

In its filing, the medical board said Sanders' failure to order periodic eye exams for the patients to whom he was giving Seroquel was an "extreme departure from the standard of care."

It is my clinical opinion that eye exams are unnecessary. It is a fact that most psychiatrists don't even know what slit lamp actually is, let alone order it for the majority of Seroquel patients. And, therefore, I am absolutely certain that those two facts alone make it impossible that his actions were a departure from the standard of care, let alone an extreme departure.

Let's be forensically rigorous. The law doesn't ask if the treatment is bad, it asks if there's malpractice, as defined:

breach of standard of care-- what a "reasonable minority" of docs would do
a harm occurred

Not majority-- minority. If 20% of docs think slit lamp is unnecessary, and they have at least a quasi-united voice on that matter, it is not negligence. And regardless of whether 100% of docs do it 100% of the time: unless someone actually got a cataract, it's not a lawsuit.

Further: it isn't what docs think, it's what they do. Example: it is now almost universally accepted that blood sugars should be monitored for antipsychotics. However, this is not in any way close to a universal practice. So it's not negligent. I'd argue that if blood sugars were monitored even once a year, it's not even a discussion of negligence. It sucks, there should be some punching, but not a finding of negligence.

And again: if they didn't actually develop diabetes, there is no malpractice.

So for the Board to discipline Sanders for, among other things, the lack of eye exams, seems preposterous.

Which brings us to the question for today: was this news story wrong, or was the licensing board out to get him?

II.

I looked up the Board's Edward Sanders Decision (PDF: reserve 30 min for downloading.) If the information there is to be believed, Dr. Sanders was clearly up to some nonsense. Billing for visits he never conducted, acting as payee for patients on SSI, altering records he sent to the Board (NB: don't ever do that, it's a trap; when the subpoena for the records comes, they already have a copy.)

But, unfortunately, contained within that document are a number of "Acts and/or ommissions" which, while nominally wrong, are things I see doctors do routinely, without malice: coaching patients not to work more than X hours because it would sabotage their disability payments; billing for a diagnosis that the patient (theoretically) had, but was not what was being treated (from memory, don't quote me: billing for urinary tract infection but being treated for asthma, but had both). For example, the payment is the same regardless of diagnosis. I can't tell you how many psychiatrists bill "296.3" (depression) as a default.

Having it all mixed together-- indeed, in not restricting the case to the things which are clearly wrong-- the Board does itself a disservice by appearing to be engaged in a vendetta/witch hunt, etc.

Indeed, a cursory reading of the Decision could very well leave one with the distinct impression that the thing he did wrong the most-- the thing that the Board talked about the most-- was prescribing Seroquel and Abilify:

[Sanders] was not surprised to learn [from the Department of Human Services invesitgator] that was the largest prescribing physician of Seroquel in California.
Well, someone has to be, right? And unless you're accusing him of kickbacks (which they are not) then it shouldn't be in there.

So, for what it is worth-- and it is worth nothing-- my opinion is that (if the information in the Decision is accurate) the Board seems to have had legitimate problems with Sanders, but they were not well articulated or focused in their Decision.

III.

That's reality, anyway, and as long as it took me to look all this up and write this post is twenty times longer than anyone in America will ever spend on researching the actual facts of his case now, post Decision.

Which means that we all just swallowed the Blue Pill: the only remaining accessible document about the Sanders case is the news article, which equalizes Medi-Cal fraud with prescribing Seroquel without an eye exam.

And so it goes, another bit of preposterousness becomes true.

Welcome, as the magus said, to the real world.

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===== ====== ===== The Last Psychiatrist: "[You, not I, are] killing people on a grand scale"

A much lauded/quoted report, the World Health Organization's report on social justice
The report detects the subtle causes of social injustice in the world, adeptly avoids simple left/right political tropes and outlines several concrete steps to reduce inequality in an urgent and immediate way. That was the plan, anyway.
Instead, it concludes the introduction: "Social injustice is killing people on a grand scale."
The report is here, but I've chosen to link the Slovakian version of the 7.8MB pdf because if you read the English version The Ring will get you, it gets everyone. From now on, you'll want to sleep with a gun and a crucifix under your pillow. Works for me.
That the report is so politically biased as to be useless is not here the point, that's for Glen and Rachel to argue. The point, rather is to show what the purpose of such a document is, why it exists in a medical journal, and how social policy reform is now executed by a few, covertly.
First, simply to show that the report's recommendations are not just vague or impossible, they are not even comprehensible. Here are some specific recommendations, chosen entirely at random:

Set up an interagency mechanism to ensure policy coherence for early child development such that, across agencies, a comprehensive approach to early child development is acted on.

Fie upon it. Here's another, this one was in bold:

Adopt a social determinants framework across the policy and programmatic functions of the ministry of health and strengthen its stewardship role in supporting a social determinants approach across government.

A short one, I assume written in Fortran:

Institutionalize and strengthen technical capacities in health equity impact assessment of all international and national economic agreements.

And you'll say, "oh, come on, that's not random, you're just selecting them out of context." Enjoy your context:

Don't ask me how I know this, but I am 100% certain this report was typed on a Mac.

The ones you can understand make you a bit uneasy, even if you're for them:

Strengthen gender mainstreaming by creating and ﬁnancing a gender equity unit within the central administration of governments and international institutions.

•Create a dedicated budget for generation and global sharing of evidence on social determinants of health and health equity.

•Build national capacity for progressive taxation and assess potential for new national and global public ﬁnance mechanisms.

A working definition of social justice is you get what you deserve and you deserve what you get. The report is free and in the British Medical Journal, so in that sense it is supremely just.

II.

Now, to why the report exists, what is anyone supposed to do with it?

None of these recommendations can or will be implemented, and, indeed, this report does not exist for that purpose. The report is pure Borges. It exists not to be read-- it wouldn't even matter that it was actually written, so long as people believed it had been written; it exists in order to be referenced, to be able to say "the WHO says that social injustice is killing people on a grand scale" (4500 hits); to validate individual's opinions as if they were grounded in science. The idea is to create a scientific basis for an ideology, in the absence of science. In psychiatry we call those "thought leaders," and the rest of you laymen call them "experts."

For example, the report allowed this professor of clinical epidemiology to say:

Pointing to the harmful health consequences of the"market oriented economic policies" pursued since the 1980sthat have led to a "significant reduction in the role of thestate and levels of public spending and investment," the reportprovides evidence that equity oriented growth can produce thehealth gains of development without the adverse effects of growththat favours the "interests of a rich and powerful minorityover the interests of a disempowered majority."

Fortunately, he knows that the data to which he refers is-- his words-- "not value free." Unfortunately, he thinks that's a good thing.

Don't get sucked into arguing about this on the basis of politics. Argue on the merits of the data. Otherwise, these politically motivated interpretations of reality will lead to stunningly idiotic policy decisions, such as the one quoted by this person who I assume has meningitis:

"If we could do something aboutprevention, we could empty the hospital wards."
Really? Can the editor of the British Medical Journal be simultaneously politically indignant and naive to think that hospitals fill because people are sick?

III.

So if that's what the report is for-- to serve as a superscript to someone's personal proclivities-- what is the basis of that report? Not what does it say, but what is the underlying thesis?

Gas up your airplanes.

Part 2 soon.

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===== ====== ===== The Last Psychiatrist: Youth Suicide Rates Up? Not So Fast

The headlines read, "Highest increase in youth suicide" and "girls aged 10-14 increased 75%." And of course, the only explanation anyone seems to want to debate is antidepressants: was it too many prescriptions, or too few?   And self-righteous indignation all around.
Well, I did something apparently no one else cares to do: I looked up the individual suicides. They are individuals, right? With different reasons for doing things? And guess what? I have another explanation: Ohio.

The year in question is 2004, the most recent year the data is available. I focused on girls aged 10-14, because that's what the majority of the news articles focused on. Most reports described an increase of 75%, from 56-94. I actually found 98 total suicides in this group.
If antidepressants had any effect-- in either direction-- then the increase should have been spread out throughout the country.
Most states had very few suicides in this demographic. Maine had zero. North Carolina had 1. Oregon, 1. Florida, 1. Etc. These small numbers are generally unchanged from 2003. California, which had the one of the highest absolute number of suicides, had 6 in 2003, and 7 in 2004.
If you look at Ohio, however, you see something interesting. In 2003, there were no suicides. In 2004, there were 11.
Indiana was next: 0 in 2003, 6 in 2004.

This, of course, speaks to the problem of medicine’s over-reliance on epidemiology. People are different, and even “matched controls” have such variability that association studies are often nearly useless. This is even more true in psychiatry. Suicide is not an involuntary pathogen, it is a complex, volitional behavior whose causes can only be meaningfully investigated at an individual level.
I have to go back and look closely at all the states' data, etc.   But it seems to me that when two small states account for almost half of the entire increase in the suicides, we should stop talking about antidepressants and maybe go find out what the hell happened over there?

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===== ====== ===== The Last Psychiatrist: You Want To Be Don Draper? You Already Are

One of these is Dorian Gray, the other is the picture

Part 2 in a series, only for those for whom it is written. You know who you are.

(Part 1 here.)

I.

Some say that the desire to be Don Draper is really the desire to live in a simpler time with established gender roles, a romanticizing the past. That's a girl talking. When a guy fantasizes about living in the Middle Ages or a different planet of Don Draper's America, they're not wishing for a different environment, they're wishing for a different movie. It's not the setting, it's the plot. No one wants to live in 500 AD; they want to be in King Arthur's court, with a certain kind of adventure, or relationship, or... they want to be somewhere where most of the plot is already known: I want that to happen to me.

Even when it's a real historical time, even one as well detailed as the one in Mad Men, what you want isn't to be alive then, but to be in that show.    They want a movie in which the main character (you) already possesses a character that everyone accepts (you don't have to be like Don Draper, you are Don Draper, and everyone knows you as that kind of person), act in any way you want; and though there will always be consequences and miseries and laughter and whatever, no matter what happens it always happens about you.

II.

A key plot point in Mad Men is that Draper's coolness and masculinity is artificial, it is an act. That's fine, everyone has an act of some kind, why not be cool? But when you choose your own act, be careful you do not choose to act like someone else who is themselves acting.

This is why, whenever someone tries to affect the style and mannerisms of a character in a movie that other people have seen, it makes the other people cringe; it always looks horrifically fake. We already know what the original looks like. If you're get on a bus to go to a sci-fi convention and are dressed like some kind of alien, you're judged by the, well, coolness of your costume. But if you dressed like an existing alien-- like a Dalek-- people on the bus will think you're an idiot. The better your costume, the more people will hate you.

It's even more difficult to emulate Don Draper, because Don Draper is already emulating something else (forget about Jon Hamm for the moment.) Draper (on the show) can get away with it because no one is familiar with what he's pretending to be (some construct in his head) so they can believe it's really him. You can't be Draper because we already know Draper.

Being someone else is very hard. Sometimes, even if you are actually who you say you are, it can still be fake. When an aging rocker tries to dress all cool and rock starry, it's creepy, because even though he is authentically a rock star authentically himself, he is still faking it: he's pretending to be who he was 30 years ago. We already know who he was 30 years ago, and that's not him now, so this impersonation is obviously, pathetically fake. Stop it.

The only time we tolerate this is if we are at an aging rock star's concert: because we're all aged by that point, and we'd all like to pretend, if only for a little while.

It goes both ways. Don Draper is 36. If you are 26, is there any way you could be Don Draper and make it legitimate? It only works if you're in your late 30s, because the game he is playing is "I've seen it all." You haven't. You can't fake it, any more than you can fake playing the guitar. It's fake. She can tell. She may not tell you, but she can tell.

III.

"Can't I just borrow some of his characteristics?"

I know, it helps your social anxiety; I'm pretty sure no one wants to be Don Draper because they think it will help them pass a midterm. Ok, so what will being Don Draper get you?

Suave? Cool? Sophisticated? Because I've written those three words, it appears that those are three things you could copy. But Draper doesn't actually possess those three things, he is conveying those three things. He has branded himself as a guy with those three things; just as Nike has branded itself as a certain kind of shoe that isn't made of inferior leather in a sweatshop. Draper the brand is a guy with a nice suit, but that suit is a brand, too (Hickey Freeman?)

Note how uncanny it is to see him in bed in the morning, without a suit.

If you want to emulate Don Draper, you will get the same exact outcome a) if copy his persona but wear your clothes, and b) if you wear his clothes while keeping your own persona. They're all brands, they're all equivalent, and no matter what you choose the girl will figure it out the moment she purchases you.

"No, you're wrong, you've misunderstood me, I feel like you're almost giving me an answer, but you're missing something, you're not getting what I'm asking. He is cool and sophisticated. That's why he can pick up girls so easily. I want to do that, I want that secret."

You can't emulate Don Draper, and you think the problem is that I've misunderstood?

I understand you very well, I've seen you in action. When I'm in a bar-- and I have been in a great many bars-- I watch the show. Life has become so much a copy of TV that I sometimes forget to pee because a commercial hasn't come on. In one show I watched you were standing with a beer, staring but not staring, talking with your friends about things that interest you, but trying to figure out the right conversation to have with the girl across the way who probably would not be interested in those things. I saw you. I saw that there were the female equivalents of you in that bar, too, but you didn't see them.

In every case the problem is the same: you don't want what you think you want. And the type of girl you think you want sensed this the moment she saw you. That's why she was pretending she didn't see you. Or did you think hot girls have no peripheral vision?

IV.

So you want to be Don Draper? You are. No, that's not a motivational speaker's empowerment mantra, it's a sad, unfortunate truth. Or a warning, if you choose to listen.

Look at your suave, sophiticated, masculine Don Draper. He married a beautiful woman; you will, too; and like him, when you get her you won't be happy.

But forget about marriage, who has this well hung lothario seduced? Has he had affairs with sexy secretaries, bedded underwear models?

No, he's had none of that; the three affairs he's had in two seasons are a hippie artist with numerous other men in her life that she likes more than him; a beautiful owner of a department store-- hardly one night stand material-- who actually hopes it is going to turn into a marriage; and a woman as marginal as she looks. These are the conquests of the great Don Draper. Real women, to be sure, but none of them are who you'd want, right?

And in every case, these women dump him the moment he reveals to them the black, infinite, starving neediness inside him. "I need you now!" he says to his mistress. She does not mace him because it had not yet been invented.

Don Draper is that worst of all possible men. Cosmo warns its future starlets to beware the heartbreaker, but what girl doesn't want her heart to get broken by a great guy? None of Draper's conquests have their hearts broken; they have their spirits broken. He's not a cocksman, he's not a player, he's not a ladies man. He is a serial monogamist, incapable of committing entirely to one person, but similarly incapable of at least committing to the playful lightness of physical intimacy and then just taking a nap. At least she'd know where you stand.   They destroy the lives of everyone around them not limber enough to leap out of the moving car. Tuck and roll, that's the secret Cosmo never tells you. Tuck and roll; but at least get out; he is driving you nowhere with a full tank of gas.

These men stay with the girl-- sometimes for years, without cheating-- but their inner eye is always on something else. No matter how desperately they think they love, they also know, simultaneously and without contradiction, that they're not really in love, and that this, too, will pass. They are immortal; there is always a future, because... because this can't be it. But they fear the future, so instead of pursuing it, they wait for it, along with the girl they've handcuffed with inertia.

These men are already Don Draper, they think because they lack his facility with gab they aren't-- but in every way that counts, at a genetic level, they are the same. If you want to see how it all turns out, watch the show.

Now maybe you understand: when a guy with moussed hair and a seashell necklace starts staring at the girl's chest and rubbing his own, it must feel to her like some kind of immense relief.

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===== ====== ===== The Last Psychiatrist: Why Zyprexa (And Other Atypical Antipsychotics) Make You Fat

this post does not apply to her, she only eats apples

Strange finding: Zyprexa makes free fatty acids level go down.

Wait, isn't that a good thing?

II. Zyprexa's effects on glucose and insulin are bad.

In a rat study of rats, using rats, Zyprexa raised glucose levels by 20%, both in fed and fasting states.

It didn't much increase insulin in fed states (already high) but it kept insulin high even in fasting states: at 14h post meal, it was 140% higher than it should have been. All that exposure to insulin, for so long. At the coffee cart, we doctors would call that bad.

III. Zyprexa's effect on triglycerides is... weird.

Zyprexa made circulating triglyceride levels fall-- it promoted the uptake of free fatty acids by various tissues:

All those tissues taking up fatty acids-- what did they do with it?

IV. Zyprexa Makes Your Body Use Fat, Not Carbs, As Fuel

Normally, after eating, your body uses carbohydrate as the main energy source. After a long time hungry, it switches to fat.

Zyprexa made the body use fat all the time:

RER (respiratory exchange ratio) tells you what's being used: 1= carbs, 0.85= carb/fat mix, and .7 is all fat. You eat, and your body uses carbs. After a few hours, your body switches to fat utilization.

In graph A, in the first 3 hours the body should have been using carbs and fat; but with Zyprexa, it was preferring mostly fat.

In graph B, every time you got a Zyprexa dose, your body switched to fat utilization instead of carbs.

V. Wait a second, why would increased utilization of fat be a bad thing?

If the body is churning through the fat, what do you think it is doing with all the sugar? Answer: turning your arteries into Twizzlers. Yum!

The typical thinking is that hyperglycemia leads to insulin resistance leads to increased fatty acid utilization. But that might be the wrong direction: it seems that the increased fatty acid utilization means sugar is unused (hyperglycemia) and remains high well into the fasting state, with consequent high levels of insulin. Insulin high too long becomes tolerance to insulin becomes insulin resistance becomes BKA.

VI. SUMMARY: A class effect, to varying degrees; and eating less may not help.

1. Food intake was the same between controls and Zyprexaers. You get these effects even if you eat the same.

2. This effect is shared by other atypicals, in a predictable fashion:

In the fed state, Zyprexa and Clozaril do a massive conversion to fat utilization, Risperdal a medium, and sulpiride minimal covnersion.

In the fasting state:

Geodon has a lesser effect than Zyprexa, and appears to normalize; Abilify and Haldol seem close to normal.

3. These effects are consistent with Lilly's own studies that the majority of weight gain happens in the first month, and not suddenly after a year of use.

4. There is still a hunger component to weight gain that is separate from the metabolic effect. Some drugs will make you hungry, change your metabolism, or some mixture of the two. Hunger appears to be a H1 mediated process (Seroquel, Zyprexa, Clozaril, Remeron, Paxil>Prozac, etc.)

5. The immediate clinical consequence of this information is probably (paradoxically) to tell the patients to eat less sugar.

Unless you dramatically cut fat out of your diet, the body will still churn through what fat you do eat at the expense of carbohydrate. Better, and easier, to reduce the carb load that lingers in your body (and likely ultimately gets stored.)

VII. Is that all the bad news?

No, of course not!

In another study (same authors, same topic, same time-- two completely different journals; thanks promotions committee, turning academics into bloggers one study at a time) they found that while there was increased lipogenesis (storage), the rats didn't have a change in body weight.

In other words, Zyprexa didn't make them heavier, it made them fatter. It increased their body fat while decreasing the lean body mass. Bright side: now they can float!

Add to this that it though caloric intake was the same, it dramatically decreased locomotor activity. So same calories, but less calorie need.

VIII. Well thank God doctors are finally going to know the truth about Zyprexa!

From who(m)?

The reality is I found these two articles by accident, researching a blog post about something else entirely. I would never have found this article, let alone the other article, on my own. And I read a lot.

Ordinarily, this kind of information would have come to me through my Abilify rep: "see? Zyprexa blows!" But the FDA now forbids anti-competitor comparisons; and neither are the reps allowed to tell me that the study exists. Promotional speakers can't mention this either. So? CME? BWAHAHAHAHAHAHAHAHA!

Here's the bottom line, and it applies to all speech everywhere: either you permit all kinds of speech, and let the truth battle on its merits; or you permit only one line of speech-- and let the truth, if it was suppressed, come up like smoke through cracks. But when you permit some speech and block others-- when you create gatekeepers of speech-- it creates the impression that the truth is in the permitted speech. Most of the time, it's not.

===== ====== ===== The Last Psychiatrist: Zyprexa's Weight Gain: Does What You Eat Matter More Than How Much?

The authors of this article have an interesting hypothesis, upon which I speculate wildly. But it is fascinating:

GLUT5, is found primarily in the small intestine (though also in muscle and kidneys.) What's interesting about it is that it transports fructose, which in turn directly stimulates additional GLUT5 mRNA expression. You eat fructose, this increases the expression of GLUT5 in the intestinal villi, which increases the transport of fructose. So the more fructose you eat, the more readily you can absorb it.

Now fructose doesn't stimulate insulin secretion. Since insulin regulates leptin, fructose actually reduces leptin. Fructose increases ghrelin. So you get hungry. Fructose goes to the liver and is metabilized to acyl glycerols, and consequently result in increased triglycerides.

So you have a situation in which Remeron and Zyprexa (and high dose Haldol) cause an increase in GLUT5 expression; if they are also eating fructose (read: high fructose corn syrup) this is causing an additional expression in GLUT5, and hunger, and increased triglycerides... if one wants to conduct a useful experiment, find out if the people who gain the most weight on Zyprexa are those who consume the most high fructose corn syrup (and not just those who eat the most.) In other words, can you gain weight on Zyprexa if you are eating Atkins?

(NB: there are many who want to believe that Zyprexa causes weight gain by increasing leptin; and so fructose and GLUT5 lowering leptin seems confusing. Zyprexa, as shown above, actually decreases leptin, acutely. (And clozaril has either no effect, or minimal lowering.) Letpin only increases with increased fat-- i.e. as a consequence of fat, not as the cause of fat. Those who have found increases in serum leptin do so only after chronic administration, and resultant weight gain (for example, in a study of 13 schizophrenics on Zyprexa who showed a small increase in leptin after 4 weeks-- and after a 2 kg weight gain; or 6 week animal study finding increased fat and leptin. The question, as noted by the authors, is whether the acute hypoleptinemia and hypoglycemia is what triggers hunger and an ultimate increase in fat, leptin, glucose and insulin. )

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===== ====== =====

	TYR PD₃₀ (mg)
	Day 7	Day 8
Placebo (n=12)	7 [4-14]	6 [5-9]
Duloxetine 80 mg (n=5)	9 [5-8]	7 [4-7]
Duloxetine 120 mg (n=6)	6 [5-9]	4 [4-7]
Desipramine 100 mg (n=11)	30 [22-82]	18 [12-31]

Tom recognized her instantly despite the red anonymity bar

Matthew McConaughey (Owen Wilson) proves there can be only one.

Do I look like I'm bluffing, bee-atch?

but they're welcome to buy an iphone

this is what women are told men want; this is how women are told how to want

everyone hates two of these: fat cats, america, virgins

Discussion

Addendum 11/15/06: Fair is fair. I found an even better review by one Eric Chudler, PhD at Univ. of Washington, called Neuroscience for Kids. (don't laugh). I didn't review all the links, but it is certainly more comprehensive than what I have here.

Effects of haloperidol 0.5 mg kg-1 s.c. (A) and 1 mg kg-1 s.c. (B); chlorpromazine 0.5 mg kg-1 i.p. (C) and quetiapine 2.5 mg kg-1 s.c. (D) on EEG spectral power in rats. Panels on the left show data from prefrontal cortex, panels on the right show data from sensorimotor cortex.

Another thing people don't understand is the fine line between Islam and Iraqi Culture. Iraqi Culture is misconstrued and manipulated form of Islam, that is strict on every level, and much harsh on women.

As I said, the only reason this situation grabbed attention for so long is because where my family comes from. Nobody will understand what went on in this house to drive my dad to this level of insanity. You guys keep talking, your words mean nothing to me. I know what happened, I know the truth.

I lost MY sister, and am losing MY father.

From An Inconvenient Truth, 2006

A threesome with the guys from A-ha.

Trevor knew if he could just win the dance off, Molly would go steady with him. But first was the little matter of his invisibility.

what could it mean?

no need to wait for the receipt

By cowardice I do not mean fear. Cowardice... is a label we reserve for something a man does. What passes through his mind is his own affair.

The irony of it all was not lost on Paris. Or was it coincidence? Irony?

Consult your doctor if you are at risk for esophageal rupture

From the video Serocool (Styx, 1981)

Tom was thankful he was sober enough to avoid the ugly one

cue hatred

for the sake of this premise, pretend she came to the 2014 Davos

no caption is possible

Effects of haloperidol 0.5 mg kg^-1 s.c. (A) and 1 mg kg^-1 s.c. (B); chlorpromazine 0.5 mg kg^-1 i.p. (C) and quetiapine 2.5 mg kg^-1 s.c. (D) on EEG spectral power in rats. Panels on the left show data from prefrontal cortex, panels on the right show data from sensorimotor cortex.