Free Association (part 22)

I went to another walk after just publishing my last free association this night. Am still on this same night. It seems that am too much alert that I may have again my insomnia. I get really annoyed how the insomnia comes to me. It comes night after night for about 3 to 5 days. My concentration throughout the day gets more bad and bad. But what is funny about it is that I made many slips of the tongue. We attended a lecture called “tool kit”. It was the first time for me that I heard about it. When we were going out of the lecture I asked my colleague this way: please can you tell me what literally a COOL TIT means? He started answering me without noticing my Freudian slip of the tongue. While he was talking I didn’t pay attention to what he was saying. I was thinking whether I really said that or I said it right. I didn’t say what I was thinking of to my colleague. I saw another colleague and we started to talk about the lecture. And am sure I did the same slip of the tongue. And he did not notice my slip of the tongue again. I smiled to my self. Well let me have a cigarette. Can I? ok thank you. Do you that I drunk about one pint of yoghurt just before half an hour. They say it contain something that help you to sleep. Was it lactate? Tryptophan? Both? Something else? I think it just start working now. So let me tell you something about my dreams these days. It is really complicated. I cannot find an explanation for them. I tried hard to find its meaning throughout this day in vain. And it starts leaving my memory am afraid. But what I can remember is that we were in a long paved way. Surrounded by a desert. We were about 5. I forgot about the other 3. I can only remember me, and a senior psychiatrist from al Mosul. We were discussing something seriously. And then came an old fashioned airplane. It was above us. a stairs made of cords came from the airplane. We started to climb it. The senior was before me and I started to climb after her. Wind came and her long wide colored clothes started to wave very hard. I became very happy then I wake up. Well I was really happy when I wake up and I felt like I found a relief from a big problem. Like someone said to me: you don’t need to worry anymore.

free association (part 21)

It has been a long time since I heard Elton John. Many of his songs were my favorite during some times in my life. Before about 2 weeks I found one of my old tape cassettes. I searched for the recorder and it was hard to find it. It was full of dust. You know, our whether, in Baghdad, is dusty. Any way I managed to play the tape. The sound was dusty too. But it was really nice to hear that song entitled "trains don’t stop here anymore" again. The electricity shut down suddenly and I was in darkness again. I searched for the candle which was supposed to be by my side. It was not. So it is time to sleep I said to myself. It was maybe about 9 pm, so I was not so sleepy. I managed to found my bed. In my bed I opened my eyes widely and all I saw was complete darkness. It doesn’t differ whether you shut your eyes or open them. I took a deep breath. Nothing to worry about, I said to my self. And then my mind asked me: where is your train now? well...I cannot remember what I thought at that moment. Where did my train of thought go at that moment. But now, am all alone, at this night, tired of my long walk in the evening, I will let my train, or let it be trains, to go roaring, listen to my free association:

Well, when Elton John singed that song telling us that train doesn’t stop there anymore, when I first heard it, It was in a period when my train didn't really stop anywhere. My train was marching slowly, in a routine way. It losted its colors. Dishes served in it were tastless. It quite it enthusiastic roaring habit. I heard that song first when I was maybe in my second year of rotation. I was in Hilla/ Babylon doing the surgical part of my rotation which was really difficult. It was in 2003, soon after the war. There was no Iraqi army nor Iraqi police. Civil people were having firearms. They still do, but to a less extent. Some of them managed to solve their problems with each others by firearms. And our emergency ward was full of bullet injuries. Police wasn’t there, so people brought their relatives shouting and running and I still can find traces of those voices in my memory screaming: WHERE IS THE DOCTOR! I used to go running and see things that I don’t want bother you to talk about…
Well all this long intro is just to say that during those tough days my love for that lady suddenly stopped. I was no longer eager to see her. She felt that. I told her we should stop seeing each other. She went. I didn’t feel anything. I was numb. Maybe as part of some kind of post traumatic disorder. Then I got that habit of taking a tab of 5 or 10 mg of diazepam before my emergency unit duty. I cannot say that it helped me or not. But I think those tabs drove me to neglect my trains more. And againg my trains were marching in more tastless routine and they didn’t stop in any station till I end my rotation in surgery and started my rotation in medicine. I stopped that diazepam habit. One of my trains suddenly stopped next to a young lady, a very religious one, a very beautiful one, and well educated. She was caring for her mother who was admitted in our ward. I noticed that she was reading one of Shakespeare plays in English having an old dictionary by her side and isolated from all others. Treating me with a marked respect she leads me to stop my train next to her, go out of my train, and look into her face as if I never saw a woman for that last 8 months (the period of my silent continuous routine journey in my numb train). I treated her with great respect. I respect all other patients, but the color of the respect ticket I gave her was of a different color. I stopped listening to Elton John and shifted to Phil Collins and his album TESTIFY. And my nights get more beautiful thinking about her. She was so serious. I felt that she will never think about me as a friend. She was dealing me as the resident doctor who cares for her mother at evening and night when the senior, whom she prefers due to his experience, was not there. Seniors work from morning to afternoon only. Till one day I told her that the new drug her mother needs is in the hospital pharmacy in the first floor (the medicine ward was in the third floor). It was late in afternoon and the worker responsible for bringing the drug was having his lunch. I told her if she wants to go by herself I would accompany her if she likes. She agreed. I cannot remember exactly how I break for her the news that I like her but am sure I was so cautious and so polite and was saying that little by little with great respect. I think I told her that I was thinking about her sometimes and that I found her special. But I think I end telling her if she thinks that we can be friends. Friendship between a male and a female in our culture doesn’t differ too much from love. It is either you are not friends or you are husband and wife. That something in between means love that is forbidden. And sex hides secretly between the lines. She was….well…I don’t want to theorize about what she felt deep inside her, but she said something like: my culture and values prohibit me from responding to your request. She said something vague as I can remember. But she let me feel her annoyance from continuing to walk together. I remember I asked her finally this question: ok N, I will leave you now, but please can I ask you a question? What is the meaning of the word TESTIFY? She said she was not sure about its meaning. It ends that afternoon in that way. I thought she will treat me badly that evening. I listened to Phil Collins again and again having her in my mind. As I went to the ward that day she came to me as never before, she was active, smiling, and told me: hi Dr sami, how are you….I looked for the word TESTIFY in my dictionary and it means doing a test, like testing….ok?...
I thanked her so much. I was really happy she was not angry at me.

Final examination in Psychiatry

Iraqi Board for Medical Specializations
Scientific Council of Psychiatry
Part 2
November 2007
Essay paper
Time 3 hours
Answer five questions only

Q1: a 35 year married lady with history of bipolar disorder, in her last visit to your clinic expressed a desire of pregnancy.
- how would you evaluate her for the sake of pregnancy?
- If you decide to advocate pregnancy, what actions should be taken before she becomes pregnant?
- How would you manage her if she relapses during pregnancy?
Q2: Discuss your management of a 60 year old woman presented with progressive deterioration in cognitive function?

Q3: discuss how malingering, factitious, and somatoform disorders can be differentiated? Describe the approach to a patient presented with unexplained medical syndrome?

Q4: as a psychiatrist how would you evaluate the phenomenon of violence in the country?

Q5: discuss the role of drug treatment in child psychiatry.

Q6: describe the services required for patients with learning disability. As a psychiatrist explain your role in the management of those patients and in the planning and organization of the services.

Al hilla

I miss it every now and then. Especially at bad times cause my mind would say to me in such times: what if you were now in al Hilla. In al Hilla I found people that support me the most through my toughest years. They were kind to me in a very characteristic way. During my first months there, I felt sad from now and then due to some causes, personal problems, they felt that, they did not ask what my problem is, they just supported me. I will never forget those doctor colleagues who asked me to take me for a tour in al Hilla. Sometimes I refuse. But during those time when I agree, they took me to places I never knew before, and start show me and tell me stories about those places. Some of them took me sometimes to their homes, were the most delicious plates were prepared for me. Some of them, shocked by my ignorance about the history of Islam, I only knew some of the things that were written in our school book, but never knew the untold stories. They took me to some religious places and told me about history in a very open, frank, wise way. I still remember how I was ignorant. I was a spoiled child. They percept that but never let me feel it. I still remember that doctor who knew from the first time he saw me dealing with patients that I may cause some problems, due to my childish behavior. So all he did was he started to walk with me as friendly as he can and tell me some jokes and deal with people in front of me, I think to let me see how I can, or must, act. He kept handling things with me for about 3 months. My first three months. Am sure he was not forced to do that. He just felt that it is his duty to teach, in a friendly, this young doctor who seemed immature. Till he felt that am SAFE to deal with people and medical emergencies, then he left me. I kept missing him. I started to accompany him during his working hours, and he was happy about that. Yeah, he is really a man to respect. A man who help you without letting you feel what he is doing. I think that growing in Baghdad in a family that does for you whatever you like is very different than growing in al Hilla. Al Hilla had suffered from tough times during the previous regime. Her people got to suffer. So they grow older fast. You may theorize that people who grow in tough surroundings will be tougher. But those people were growing wiser and more kind. I even remember that I did mistakes. I made some disrespect. But all they did was to ignore it and concentrate on my good deeds. Well I will be a liar if I say that all people there are angels, there are some people who are bad, like in every society, but the most were the good people.

Wadee3 il safi

My father, during the 1990s, was working day and night just to have the little money that provides us with a small lunch. The dinner stayed an irregular possibility that made my mom irritable, knowing that her children are hungry, but they are keeping their mouths shut. We were all getting thinner and thinner. And thinner.

That was not the thing I want to talk about. I wanted to talk about my father’s mood. He was tired, quitted all his hobbies, including tennis and painting. I took his books. All of literature and start eating them. I mean reading them. I asked him from now and then about a thing I read from his books and I was really annoyed cause he did not care to talk about literature. He gave me few money each month’s beginning. About 2 US dollars. That’s all he could. I bought novels. He got angry at me sometimes. Sometimes he asked me to show him what I bought. His facial expressions were not encouraging. I got angry at him. I remember I asked him to go with me to a theatre. He said he was tired. I get angry more day by day at him.
And it was tough years. I really became a rebel. Doing anything that could make them angry. Start listening heavy metal. Turning the recorder loud when my father tried to sleep his short afternoon before he went again to work. The recorder was taken from me. And the war continued.

It is not this that I want to talk about. It is about wadee3 il safi. It was late in some evening in the 90s. When the TV showed some concert of Wadee3 il safi. My father did not hear a song for long time. But this time he came and sat smiling. And how wide was his smile. He even said “ Allah” many times while he was really in a state that I can say it was a trance. He smiled like before. I saw his face shining there in our dark main hall. You cannot imagine how I became happy. I sat little behind him just to see his face while he cannot notice me. Oh daddy I really love you when you are happy. I knew that all the hatred I felt for you was not for you in person, but was for your suffering. I love my dad who listen to music, paint, and enjoy his life.

Now I don’t live with my father. I didn’t see him for about a year and a half. I bought almost all the CDs of Wadee3 il safi and listen them every time I miss him.

Hughlings Jackson

The committee were 4 senior doctors. The first three came early. Earlier than us. The Ph.D. thesis of the 3 resident doctors who were anxious, was to be discussed on that day at 9 a.m.. They waited the forth senior psychiatrist till 9:30 a.m.. He did not come. They started the discussion. At about 10 a.m. an old man entered the room. All the seniors stood up, we followed them and stood up, and we knew that this senior is the waited one. His hair was combed, but some hairs on the back of his head were going upward in a noticeable factions. He sat. they gave him a cup of coffee and a small chocolate piece, as it was already given to the 3 senior psychiatrists. He spent his time drinking coffee and tasting the chocolate, while the discussion was going on. Till suddenly he looked at the paper in front of him and said with marked surprise:
- what is this? Hughlings Jackson was born in 1885?
- It is taken from the book sir. (answered the resident doctor whom thesis was being discussed)
- No doctor, no. be sure about it. Ok?. Please, reread your book.

After that, the discussion of the thesis continued for about 3 hours. The old doctor did not say a thing but about his need for another cup of coffee.

I got a great respect for old psychiatrists. That senior stimulated me to search for who is Hughlings Jackson. and I found the following.
He was born on 1835, died on 1911. Was named the father of the British neurology. Best known for his investigations of epilepsy and aphasia. He also was interested in psychiatry. In 1894 John Hughlings Jackson published a paper on “The Factors
of Insanities” in which he considered the positive symptoms as a “release phenomenon” occurring in healthy tissue; while negative symptoms were attributed to neuronal loss.
He was the pioneer to talk about hemispheric dominance. He studied also the dissociation state, and he made a model of the mind and the concept of the self. He regarded the sense of the self as a function of the brain that gained its high rank in development in species. He meant HUMAN. And linked the prefrontal cortex to the sense of the self. The concept of dissociaton is the reverse of evolution of species. I think he called the reverse of EVOLUTION as DISSOLUTION. Then said that dissolution occur in dissociation. In dissociation there is dissociation of the higher mental functions: memory, language, intelligence, reasoning…and others…