Monday, June 30, 2008

Between Salim's Freedome and Kahramana's Jars hide all my personalities

Those were pictures of the freedom monument made by "Juad Salim" as far as i can remember the name as my father used to say his name over and over to me and to his friends. The monument contain many symbols, each one with a story, that my father can tell you. Unfortunately I cannot remember them so good. It is here that my first contact with monuments started. My father used to take me here every time he got free time to talk a walk. It was here that I knew that my country got great artists. Juad Salim, as far as i remember the name, took a well known award from Italy, as my father was repeating. My father would add something like: "Italy, Italy, you know what is Italy? they gave him an award! Italy gave him an award"..

And I feel so proud of my father and of my country when I hear that.

My father had a friend who lived in an apartment in al Sadoon street. Al Sadoon street was loosing its importance in Baghdad. During the 80s…. during the Iraq-Iran war…. Al Sadoon street started loosing its significance as a centre of attraction. During the Iraq-Iran war, which lasted 8 years, men were taken to the battle field. Baghdad was running out of working hands. Men from Egypt mainly, and Sudan to a lesser degree, came to Baghdad to find job. Many of them found shelter in cheap hotels of Al Sadoon street. They tended to crowd in small rooms. Al Sadoon street was changing its mask from a one that was symbolizing Iraqi originality and art, into a centre providing low price shelter for strangers. My father was always arguing with his friend trying to convince him to leave the area and find a better area. I cannot remember what was that friend answering my father in detail, but it was something about that “he doesn’t want to”.
That friend was always using some perfume that I can still find some traces in my nose memory. An odor that is not feminine at all. An odor I found strange by then. Like some smell of alcohol, cigarette smoke, and sweating mixed together, but then imagine that the man with this odor take a shower using a very sweet smell shampoo. When he came out you will smell some traces of alcohol and cigarette smoke but now they are so sweet. That was how my father’s friend odor was. It was very special. He was white and little puffy. He had no moustache. The area between his nose and upper lip was big and shining. I cannot remember what he was working. I think I never knew. I never asked. But that man represent, in my mind, the symbol of an Iraqi from the good days.

Battaween is a quarter were there are old houses. Their architecture is a special one, similar to that of Al Wazeerya. It is called by lay people as “Jewish houses”. They mean by that that they were built by the Jews. When the Jews left Iraq, there were no new Jewish building. A whole school of architect was lost in Iraq.

I went to Al Sadoon street for some work which I failed to complete due to some lack in my papers. I went walking down the street. I had my camera in my pocket but I didn't like to bring it out. I didn't feel safe to hold my camera in my hands there. Somebody may think I am a journalist, and this is dangerous. Or somebody else may think I am preparing for something bad, who knows, may be an explosion. We are getting paranoid and this is normal. Baghdad is not that safe that you can hold your camera and take photos.

Al Sadoon street starts with a square and a big monument, and ends up in a small square and another nice monument. The first is about freedom, and the second is about 1000 nights and a night and kahramana.

My father used to take me for long walks here. But it is changed now. I was containing the largest cinemas in Iraq. With the most numerous doctors and lawyers private offices. Now they are closed. Not here anymore.

In al Bataween lived the lady that was taking care of me when my parents aren't home. She educated me in her way. She talked to me about Al Bataween and about Sami, a man with a name like mine whome she was deeply in love with. She talked to me about how strong and brave he was. And how hadsome. She talked to me about cinemas and Indian romance films. And she was christian, so she talked to me about christianity. I remember once, a young woman, who didn't like that lady who took care of me, taught me two lines of rhyme and showed me how to sing them. It was something about the Virgin Mary. She told me to sing it for her (the lady that I don't want say her name but her name is written in my heart) and that she would be happy. I went to her and sang that song, she started crying while the woman who taught me started laughing loud. I knew it was something bad. I knew i just humilated my lady and her religion. My lady took me away, I started crying.

I intered Al Mada publishing company and my eyes were caught by a book at the far top of the wall. The worker was busy showing some old men some books written by "Hadi Il Alawie". I started walking around in the big book store. I didn't like anything but that cover of that book up there. I went back and stood like a statue with my neck hurting while I was looking up at that nice cover. I even couldn't saw the cover in detail. It was so far. So high. But the colors were telling me: "come and get me, you should read me, you should have me in your hands".

The old men went out and the worker came to me and I told him that I need that book. He brought his stairs and went up. I added at the moment he touched "my" book: and I want to see that next book, Presto and I? Platero and I? what is that?

The worker asked me: this brown book?

I said: yes, the brown book please.

I came home with Dr. Jekyll and Mr Hyde of Robert Louis Stevenson and Platero and I by Juan Ramon Jimenez.

I didn't know them both before. But now I know that I should have know them both earlier. Anyhow it is not late to know them.

Jekyll and Hyde is about a man with multiple personalities. If somebody had told me about this book i would have travelled earlier to Al Sadoon Street to buy it. But it came just by accedent. And what an accedent. I just fall in love with the book from the first sight with no clear cause. I think the single cause was the cover and how it is different from other book's covers. Another possible explanation is that I have read the title somewhere else and had known that it is about multiple personalities but that this information had passed with time from my conscious to my unconsious. Does Elton John have a song with "Jekyll and Hyde" in it?

When I took a pause from reading Jekyll and Hyde and was thinking about how it was a happy accedent to buy this book, I thought about me myself and whether I may got a double personality. do that exist? I said to myself. And how it would be if I have another personality, what kind of personality it would be?

Then my thought stream reached an area where I start thinking about the other book, Platero and I by Juan Ramon Jimenez. Why I chosed it at the last moment and i didn't know about it anything. (I still don't know anything about it cause I didn't read it yet). Then an idea came into my mind saying: "both these book talks about 2 identities, one is clear to the other, the other is hidden or mystic,..., if I have another personality, could it be a donkey?... that could be, actually I hope so.... to be an animal with no much worries.... that would be so nice and easy,...., but I got to wait till I read Platero and I and see what it means,....., i may change my mind, i will read it and write another post, till then see you soon all of you and all of your personalities, old ones, new ones and coming ones...."

To see some wonderful pictures about Jakyll and Hyde visit this site

Friday, June 27, 2008

Shaddow Contemplation

When I first visited Al Rashad mental institute in 2005, the guards stopped me and asked who I am. After they knew that I am a doctor they asked me if I carry a camera. After I told them that I don't carry a camera, they asked me if my mobile phone have a camera. My mobile by then was having no camera. I asked them why they did ask those questions, and they told me that it is prohibited to carry any kind of camera inside Al Rashad institute.

Since then and I know it is very sensitive to take a picture to a person with a mental illness. I never did took a picture to a person without his concent. And never thought of taking a picture for a person with mental illness.

But when I started my training course in Al Rashad institute before about 6 months, nobody asked me if I ever have a camera. I even saw some kids walking inside the hospital with their mobile phone cameras turned on on a window of patients while police was standing nearby. I thought about talking to them, but they knew the police and the policemen know them, yet no body knows me at that time. So I just shut my mouth.

During my training I saw that some patients are pictured and sometimes video camera is used during some occations that even psychiatry seniors were attending.

I get less sensitive from my mobile camera during the last months of my training and I started to use it when I think it is an appropriate time and place.

I never took a picture to a face of a patient. But I think, this patient's contemplating moment in the shaddow worth to be recorded.

Thursday, June 26, 2008

My kiNdergarten loVe stoRy

I made some "silly" face and "silly" movement which was more like a clown dance. Her grandfather laughed, but she only smiled with some fear in her eyes then she run away to hold her grandfather hands. She didn't trust that I can be so close to her. She was little frightened from this "clown" in his white coat who just came from the outpatient clinic with his red cheeks, uncombed hair, white small papers fills his pocket and show themselves in an irregular way and sweat drops in his forehead.

When her grandfather took her away I kept looking at them as they were leaving. His legs are so long. He was walking at ease while she was running. I kept looking at them till he finally stopped and hold her up into his arms and started walking faster. I went inside, I locked the door, took a white paper and wrote this piece about what can I remember of her, that lady I loved when we were both 4 years old in the same kindergarten.

I loved her like I loved the ice cream
Her image walked with my nights like a moon
When she wore that white dress
I imagined her as my bride

I wore a mask of a silly child
And proposed that game of acting
I took a role of a clown
She was the princess
In her father’s castle

I approached her and said: I love you….
Her companions laughed
I smiled
She furrowed her little brows
“You clown, how dare you,
Do you want me to tell my father about you?”

I felt so sad, so small
An idea jumped in my mind
I said with a wide smile in my lips
And tears in my eyes
“I can do some funny acrobatics”

She did not answer
Her fellows applauded
I run as fast as I can
I felt myself a jaguar
I was sure all were impressed
I jumped high like a bird
All opened their mouths wide
I flipped
I fell
They all laughed
Her cheeks turned into red
I thought it was for me when she shouted
“Here he comes”

The prince came
He was clean and neat
He was confident
The party continued while I was forgotten

The teacher came with all her pride
She brought us a cake with a delicious aroma
They all ate
I didn’t
“Don’t you like my cake?”
“I’m not hungry”
“Don’t you like its aroma?”
“I like her smell more”
“The princessssss”

“He just said he likes your smell”
She looked at me and shouted:
“You’d better smell your ass”
A wave of laughter made me drown in my tears

She took a blind stone and hit me in chest
I walked as confident as a king and said
“This party was for you”…

Tuesday, June 24, 2008

ACHEWS, sorry I am allergic to happiness

Dysthymia is one of the mood disorders that I never did diagnose till I bought this book. It is so easy how this book make it:

"2 of these 6, with depressed mood, for 2 years sugnify dysthymia:

Appetie disorder
Concentration deficit
Enegry deficit
Sleep disorder

The dysthymic patient is "allergic" to happiness; hence, the mnemonic refers to a dysthymic patient's (misspelled) sneezes (achoos) on exposure to happiness".

Those were the few lines about dysthymia in this magnifisant book. I looked for the book to take a picture of it. I thought I may found it next to a nice thing so that the picture will be nice. I found it lying above other books turning his face away from them. "You are special!" I said to it.

Monday, June 23, 2008

Stefan Zweig

Today I bought the newspaper from Al Rasheed Street. They don't sell newspapers in some areas in Baghdad, like in the area where I live and the area where I work. So I felt happy that I can buy a newspaper. They even gave me a free edition of Stefan Zweig novel "Chess". I didn't know about Zweig. I only heard his name and I cannot remember anything about that. Today I knew how wonderful are (is) his writings. He was talking about 2 types of intelligence in that novel. It was great.

Sunday, June 22, 2008

Riding Jeeps

This is another picture for these Jeeps that take me to my working place. The driver won't start driving his car till it is full of passengers. The car is not considered really full unless 2 or more young men are standing on the back. I don't like to consider myself as different from most of my society, so I decided that I must stand at the back one day. When I did that one day I was holding a nylon sac with some books inside. I put it between my legs and was ready for the ride. The street is not well paved all long. Believe me I was afraid. I decided I never repeat that. But one day the car was full and the driver stopped for 2 women. The young man who was sitting in front of me stood up, walked to the back, stood there. I knew that it is my turn to go and stand at the back to let the 2 women come inside. I and that young man were sitting on the last seats near the back, so it is we who should stand on the back if women came. I stood on the back and I was having a sac full of books and some clothes. The driver went so fast. I decided that the woman who took my place should hold my sac for me. I bent so that I can talk to her. Before I finished my asking she smiled and said "sure my brother". She took it from me. I felt that we are really brothers and sisters suffering from difficult time hoping that the future will be better and that these Jeep cars will be of history. But I am already missing them, that is why I am taking photos for it just to keep them in mind.

Tuesday, June 17, 2008

Condalisa Rice with 2 pens and a tooth

When he knew that I will leave soon he told me he wants my pen as a souvenir and that he would give me 2 pens instead of it as souvenir. I agreed. He went running and came back with those 2 pens.

I gave him my pen, thanked him and went walking toward the female ward where they wanted me to do an ECT "Electro Convulsive Therapy". I met the patient. She was frightened. The senior had requested ECT for her. She is frightened of it. She doesn't want it but she is an inpatient in Al Rahsad hospital, and patients here don't have the right of refusing treatment. Their families sign a paper at the first day of admission giving the permission of an ECT at anytime the doctor prescribes it. She was clearly depressed with marked irritability. I didn't make a long interview with her because all what she was saying is that she doesn't need an ECT. We don't have anesthesia for ECT. So she will be awake till it starts. But she will not feel anything till it ends. The fright of being "electrified" is understood. But what can I do. I started telling her that it is not called an ECT anymore, but it is called nowadays as Electro Stimulative Therapy. And that it is easy and she won't hurt and that I will do it with my hands and she doesn't have to worry. They changed the word "Convulsive" into "Stimulative" because when they use anesthesia no convulsion will appear on the body, the convulsion will be recorded only via the EEG "Electro Enchephalo Gram". But in our case it is still an ECT. But I was trying to show her that it is a treatment and not a punishment and she was feeling. I noticed the bad health of her teeth. I asked the nurse whether a dentist saw her; the nurse answered me that they didn't come since March when the gun fights started again around the hospital's area. I asked the nurse if she thinks that a tooth may fall while we do the ECT and she answered that this same patient had received an ECT before short time with no problem. I asked the patient if she got a tooth that is not stable, I mean moving. She said: yes. But she showed me a tooth that is stable. The tooth that I was worried about was not mentioned by her. I looked at the other nurse standing near the cleaner preparing the bed. It is not a bed; it is a big piece of sponge put on the floor with the ECT instrument next to it, with a mouth piece prepared to be put in the patient's mouth so that she doesn't bite her tongue. The other nurse encouraged me to do the ECT and we did it. One of her bad front teeth fell to the outside of her mouth. I thanked my God that it didn't fall to the inside where it might cause suffocation. The nurse became little shy and avoided looking at me. I blamed myself and not the nurse. Then I project my blaming to the hospital and its negligence. After few hours I started again to blame my self and I knew that this woman might have been killed by what we did for her. And we would call that as a SIDE EFFECT, when it is clearly our ignorance, neglect, and inhumanity.

When her tooth fell I took it in my hands. I took a picture for it so that I won't forget her. This is her tooth.

At the evening I was really in depressed and irritable mood. I wondered if a senior prescribe an ECT for me how it would be experienced by me? I was ruminating with some ideas till my door was knocked. I found him, the same patient who gave me the 2 pens. Now he brought me another present that he had just made manually. It is a small sac made from the huge sac of rice. A sac that is very strong. He showed me that it is from the USA, and he added that it is the best quality of raw material to make strong sacs that bears heavy weights. I felt so happy. I thanked him. He felt my happiness. Before he went he added that they wrote the word "RICE" on the original sac. I wondered if he knew English. I wondered if he thinks that this is related to him because he got delusions of reference as I knew when I talked to him long ago. So I asked him: what did they mean by that? He answered quickly: they meant Condalisa Rice!!
When he said that, I struggled for a second to hide my threatening burst of laughter. He burst into laughter, and I followed by few fractions of a second. I laughed like I never did since many months. The sound of my laughter was so laud like his. I noticed that he lost some teeth from the front of the upper jaw. When I went inside I felt that that lady will go on with her life like this kind wonderful man is doing .


Fate. Fate is written they say. It is already written. El Maktoob is the Arabic word for "the written". Your maktoob means your fate.

It is strange how some important events happen so suddenly, so spontaneously, without significant planning.

Taking the step of choosing psychiatry as a career was never planned in spite of my obvious liking for this specialty. It was in 2004 when I was still a rotator resident doctor in internal medicine. A colleague told me that he would chose psychiatry as a specialty. I told him that I won't chose psychiatry because of the low income of such a specialty and because of the troubled neglected patients I might met daily. I told him that I would choose internal medicine. We were in Al Hilla/ Babylon. When I want back home I went to the Iraqi Board of Medical Specialties building and stood in the line of doctors, in the row, and when my turn came, the secretary raised her head from the table she was sitting behind and just looked at me, I said 2 things, my name, followed by one second of contemplation by the word "psychiatry". She wrote my name with the word "psychiatry" below it in a file in front of her.

I went back home. I went to Hilla again to find my colleague who surprised me that he changed his mind and would like to chose another career (later he came again to choose psychiatry next year). I surprised him by my step of going and registering myself there. After few weeks I entered the exam with other 9 colleagues and all of us were accepted as students in the Iraqi Board of Medical Specialization studying psychiatry.

Another important event in my life was so spontaneous and seemed as if written before it happen. It was in 2006 when I was in Mosul. I had many nice kind colleagues. But their life was difficult because of the unstable situation of Mosul. They went home early in the afternoon and I stay alone in the ward. I felt so lonely. One day, I decided the I must go to the internet café and spent time. I usually go to the internet café to search for something and not to spent time. I usually go to the internet café having a goal. I went. Opened the yahoo chat window and to my surprise I chose the "Parneting Room". Why did I do that? Why Parenting? What I was thinking about? I was thinking about nothing…I was driven by my maktoob… I entered the room and met a person who taught me friendship like nobody else did before....I never thought that chatting via the internet can affect someone like it did to me....

Thursday, June 12, 2008

Going To Work

This is a picture of the buses that I take when I go to work, the one in the far left is a mini bus named "Kia", the other one in the far right is an old Jeep car that I take as the last car to my work.

Below is another picture of one of the old Jeep cars. They were used by the old Iraqi Army in the previous regimn. Now they are colored differently by their owners. Half of them are not registered in the legal way, so they contain no numbers, and are not allowed to go outside some restricted area.

The area where the hospital lies is isolated from other areas by this concrete wall and no car is allowed to pass. The staff complete their way by walking.

Wednesday, June 11, 2008

What Can You See In The Horizon

I spent the last 4 days at Al Rashad hospital where I work and train these days. The first 2 days we had no electricity at all. The second day the whether became so dusty that you cannot see farther than about 100 meters. You know what, I start liking those dusty days because the whether is colder during it. I’m hearing his sound again. There is a chronic schizophrenic patient in the nearby ward and he got a habit of screaming the same word again and again till his mother call him. He got no telephone and the hospital got not telephone too. So she calls the nurse's mobile phone number and talk to him once in a week. That made him better for some days, but soon he will start shouting again. If you go and ask him during shouting why he do that, he will tell you that he don't know. But he will thank you that you asked. If you ask him why, he will keep quite for a while. But he will start shouting again. I can hear him from my room in the house of doctors. During the first day he was shouting something that I cannot remember exactly. I think he was just making some sound that means he was in protest against something. He sometimes bang his head against the wall recurrently he is drowsy. He is on high dose of a tranquilizer and a mood stabilizer.

I saw him that day in the evening while I was doing my evening tour. He was squatting, with his back supported by the wall and his eyes fixed on the ground. I greeted him saying “Hi, how are you…..” the nurse standing near me whispered to me his name, I added his name at the end of the greeting, “…..M”, he just smiled. I stayed looking toward him while he downcast his gaze again to the floor. I thought about what I can do for him. It was sadly nothing. There are about 1200 patients here. Most of them are not wanted by their families. The government provides food, shelter and clothes for them. The staff tries to provide acceptance and respect for them. Some of them are enrolled in the rehabilitation program of the hospital which include training in: sewing, carpentering, blacksmith working, sport and art in form of drawing (mainly oil drawing), and drama. The rehabilitation is not that active. The psychodrama is the slowest one because it is a difficult work. It is done maybe once every 2 years, and the most beautiful thing about it is the time spent preparing for it. It took months of training and of hard work for the staff and the patients.

Not all the patients are enrolled in the rehabilitation program. The main cause is the prominent negative symptoms of some patients. All patients are seen once every 2 weeks. Some of them, actually the majority, seem not enjoy being seen and talked to. They have very poor if any eye contact. And they got marked poverty of speech. My senior sometimes asks some of them: do you like to go outside the hospital? The majority answer: no. But is it correct to let all these patients with the so called DEFICIT STATE to chose their islands of isolation? should we force them to join the rehabilitaion? Was it because of lack or rehabilitation that they are so "negative"? Is it irriversable?

Al Rashad hospital is a type of a TOTAL INSTITUTION, Goffman had talked about before decades. It is a type C hospital according to the classification of Wing and Brown in 1961, which is a hospital that patients spent most of their time unoccupied in the ward, and generally treated as “inmates”, and they got little liberty, and few personal possessions, things that lead to increased incidence of social withdrawal (underactivity, lack of conversation, neglect of hygiene and personal appearance) and socially embarrassing behaviour (incontinence, mannerisms, purposeless overactivity, threats of violence, talking to self).

I know all that but now, what can I do for M. is he in receiving the best care we can offer? He got all those socially embarrassing behaviour listed above (taken from companion to psychiatric studies). Can I help in enrolling him in carpenter working for example? Or sport? But what about the others? Can the rehabilitation building find place for them? Maybe each patient can have a day in the week. One day per week. And the trainers got to agree on this cause this means much work for them. How many staff we will need?

Will patients agree that they go to work there? Did somebody try before? I don’t know. Am not one of the permanent staff, I came here last February and I will leave soon. I didn’t come to change things here, I came just for watching and learn, didn’t I?

A Genesis of a Psychiatrist (SIGECAPS=maj.dep.)

When I first knew that I should know the criteria of diagnosis of almost 300 psychiatric disorders listed in ICD-10 or DSM-IV (we are free to chose one of those criteria) I felt that am not sure I want to be a psychiatrist. I got a very bad memory.
After 2 years of helpless efforts of remembering, (it was 2 years of forgetting more than remembering), I found suddenly this book pictured above. It helped me to remember the criteria better than my seniors. Better than all my colleagues.

A dear friend told me that she find it difficult to remember those criteria, and hence to diagnose psychiatric disorders. For her, and for all of you, I will post some of the mnemonics used in this clever book to help us remember the criteria of most important disorders.

SIGECAPS was devised by Dr. Carey Gross as a mnemonic for the criteria of major depressive disorder at MGH and refers to what one might write on a prescription sheet for a depressed, anergic patient: SIG: Energy CAPSules. Each letter refers to one of the major diagnostic criteria for major depressive disorder:

Sleep disorder (either increased or decreased)
Interset deficit
Guilt (worthlessness, hoplessness, regret)
Energy deficit
Concentration deficit
Appetite disorder (either decreased or increased)
Psychomotor retardation or agitation

4 of those 8, with depressed mood or anhedonia, for 2 weeks signify major derpression.
The picture of the band Genesis came by accedent near the book at my table and hence the picture and the title.