Wednesday, August 13, 2008

Loosening of association

Most of the DVDs where used. I found "The Vally of Elah" lost in the box of the old films. I noticed that the DVDs nylon cover is very clean. I opened it, "it is not used", I murmured to myself. At home I was so alert watching the film in the darkness of my room's vally whose lights are shut off deliberately due to some tension headache claims.
Tommy Lee Jones looked at me with his eyes. His gaze was intense. I stopped drinking my Tamarind juice holding the glass with my confused hand. He said: "Sami, I used to be like you, an energetic clever young man"…

"hey hey wait…" I yelled, putting the glass above some papers in the table "I am not energetic, and I am sometimes very stupid….remember how I lost her friendship? I shouldn't said that to her…she is married and we were friends…why do I always fall in love with married woman? Is this a fear from commitment? A fear from marriage? A fear from real love? Am I afraid that love may destroy me?"
"hey hey now you stop shrink" he yelled.."what the hell are you talkin! Put all your shrink trash in your papers and let us talk about life….or death maybe cause what is happening in the valley of Elah is really depressant…"
"Tommyyy com on I thought that you are a flag-waving man" I said…
"forget about the flags"…he said then he stopped looking into my eyes…he looked really depressed

"tommy…we need to forget about our problems.." I said while I retake my glass of juice and took a sip and contiued: "I lost a friend…you lost a son…flags are.."
"DON'T EVERR..NEVERR MENTION FLAGS AGAIN!!!" he yelled and then shout suddenly "UNDERSTAND!!" I droped some juice on my pijama..
"okay man?" I said….he ended his second episode of intense eye contact by looking in the nowhere sadly.... "I ….I was just…..I…" I noticed that he tried to look into my eyes again and he did… but this time his eye contact was benign…so I continued with my "I"s: "i….i….that story of the valley of Elah, was about David? King David? Prophet? Hmmm?" before he tried to look into my eyes again the electric power was shut off….i was in complete silence for few seconds… then an old woman with a beard and three broken teeth in her hand came walking till she stopped in front of me. I pul my chair backward. "They are three DAVIDs I want you to remember" she said while she sat at the bed which lies behind me. I turned my chair to face her. She continued: "David the first" then an overhead projector light shined from her eyes to the wall near us. I saw this picture:

"He looks like me...he he heee"...she said smiling then added "ihm ihm...let us talk seriously...Psychiatry is lucky in having a movement of criticism called "the antipsychiatry" . The term "antipsychiatry" was coined by a psychiatrist called David Cooper.

In "Oxford handbook of psychiatry", the mention of these critics was preceeded by the following words: " They are presented here for historic interest and so that the sources for modern-day advocates of these ideas can be identified."

Oxford hadbook of psychiatry also states that: "All psychiatrists should retain this healthy scientific scepticism and be prepared to question their beliefs about the causes and cures of mental illness."

She shut her eyes and the photo dissapeared. "That was the first David I wanted you to know about. The second one is....." She opened her eyes wide and an overhead projector light shined from her eyes again focusing itself on another wall revealing this picture

"Rosenhan....David Rosenhan.....I respect those antipsychiatrists because they dare to be so. I remember and mention always an experiment done by David Rosenhan, a psychologist. An experiment that is very famous and is mentioned by the wikipedia like this:
"Rosenhan's study consisted of two parts. The first involved the use of healthy associates or "pseudopatients," who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in various locations in the United States. The second involved asking staff at a psychiatric hospital to detect non-existent "fake" patients. In the first case hospital staff failed to detect a single pseudopatient, in the second the staff falsely detected large numbers of genuine patients as impostors"....

She blinked and the light was gone...

"The third David...." while she said that I sighed...

"you must be bored…then I should go now…" she started to be transparent a little by little till she dissapeared.
The next day I was walking. My foot took me to the library and stopped in front of a shelf of old books. My eyes looked at that book entitled "The Divided self/ Ronal David Laing". One of my hands took the book and put on the table. My mouth, with aid of some other organs talked and said: "may I have a paper, please.". the librarian brought a paper and put it in front of my body. my hands started copying from the book the following lines:

"in many schiaophrenics, the self-body split remains the basic one"

"in its final form, such complete disintegration is a hypothetical state which has no verbal equivalent"

" a certain amount of incomprehensibility of a schizophrenic speech and action becomes intelligible if we remember that there is the basic split in his being……"

"the individual's being is cleft in two, producing a disembodies self and a body that is a thing that the self looks at, regarding it at times as thought it were just another thing in the world. The total body and also many "mental" processes are severed from the self, which may continue to operate in a very restricted enclave (phantasying and observing), or it may appear to cease to function altogether (i.e. be dead, murdered, stolen)."

"yet these irreducible difficulties are practically certain to be much increase, at least in one's first encounters with the patient, by his or her deliberate use of obscurity and complexity as a smoke-screen to hid behind. This creats the ironical situation that the schizophrenic is often playing at being psychotic, or pretending to be so. In fact, as we have said, pretence and equivocation are greatly used by schizophrenics. The reasons for doing this are, in any single case, likely to serve more than one purpose at a time. The most obvious one is that it preserve the secrecy, the privacy, of the self against intrusion (engulfment, implosion). The self, as one patient put it, feels crushed and mangled even at the exchanges in an ordinary conversation. Despite his longing to be loved for his "real self", the schizophrenic is terrified of love. Any form of understanding threatens his whole defensive system. His outward behaviour is a defensive system analogous to innumerable opening to underground passages which one might imagine would take one to inner citadel, but they lead nowhere or elsewhere. The schizophrenic is not going to reveal himself for casual inspection and examination to any philandering passer-by. If the self is not known it is safe."

"the self at the same time longes to be understood; indeed, longes for one whle person who might accept his total being, and in doing so, just "let him be". But it is necessary to proceed with great caution and circumspection. "don't try", as Binswanger puts it, "to get too near, too soon".

When I complete copying I started starring at this picture of R D Laing, which started to be smaller and less clear

Then the picture above transformed into another picture, and R D Laing now is Antony Hopkins....waooww..

Have you ever seen how Antony Hopkins is great? Did you see that film when Antony Hopkins behaves like a gorella? He is a great man....and do you know that during my teenage years I fall in love with Judie Foster? But the problems started when one day I saw this series in the Iraqi first channel I fall in love with Cybill Shepherd from the first sight. Judie foster get jealous. And the war begins between these two ladies on me.... And you cannot believe it, they are really wild..... Judie Foster got a psychological trauma and wanted to separate from all human beings after our sad sad bitter story. She said that she don't want any contact with any other human, but her father, as she said. She chosed a very strange career, she chosed to be an astronaut!!!

That's what happened to Judie after our stormy love. What happened to Cybill is unspeakable.

Finally, all my apologies for my Loosening of Associations...

A last thing, just see how beautiful Cybill Shepherd now...

Wednesday, August 06, 2008

treating my homophobia

I knew about homosexuality when I was in my teenagers. Those who were homosexuals at my school were disgusting for me. They were abused by many as I can remember, and they were behaving like prostitutes. They got multiple partners, and they seemed always to be happy and showing a silly smile that made me irritable in their existence. We thought, as many Iraqi doctors still think, that the problem is in their anus, and not in their brain. They are described in the Iraqi slang language as “having worms in their anus”.

Today I have seen the first case of gender identity disorder as a psychiatrist. He was born as a male. He believed since he was 5 years old that she is a woman entrapped in a body of a man.

He is very polite. Presented with disturbed sleep. He accepted to be presented by one of my colleagues in a case conference. I thought at first that he likes to show himself. As if searching for a handsome man to have some affair with him. He came to the conference today putting a lipstick. I said to my self “he is impolite” when I first saw him.

As the conference reached the point of asking him some questions, I noticed how polite and clever he is. He told us about his suffering. He told us about his trials to change his feelings. About his feelings of guilt. About his prayers to God. He has only one partner at time being. He dreams about being a female and marrying to a man and having a baby.

He respects himself in spite of the guilt he has. He made us respecting him. It was very important for me to feel that I am not irritable next to someone who is homosexual. What helped me in that were his neutral eye contacts, respect, and politeness.

I studied about gender identity disorder.
I found that it was called before as Onanism. The term came from the name of Chevalier d'Eon de Beaumont, whom I searched for his picture in the net and found that as a child I saw a related cartoon named "Lady Oscar". The picture below is from the cartoon of Lady Oscar.

I remember that I liked the soundtrack of this cartoon like many Iraqi kids did.

It is not clear whether lady Oscar and d'Eon de Beaumont are the same person or not. But it seems that d'Eon is a real person while Lady Oscar is a hero in a novel.

In psychiatry literature, the condistion was mentioned by Esquirol in 1838. This a picture of a statue of Esquirol, a french psychiatrist, but I don't know where the statue is.

The condisiton was described in more detail by Krafft-Ebing in 1886. Below are two photos, the first is for him and his wife, and the other is a cover a one of his well known books. And in the recent time, Harry Benjamin had studies the condition and he found the Harry Benjamin International Gender Dysphoria Association. Here is his picture below.
I found that there is a syndrome after his name, the "Harry Benjamin Syndrome", but it is not mentioned in neigther of my 3 textbooks "Oxford (shorter); Companior to psychiatric studies; and kaplan and sadocks". It seems that it is another name for Gender Identity disorder which is also called transexualism.

Tuesday, August 05, 2008

Marouf Al Rusafi

Iraq history is full of men who need more light to be shed on their dark forgotten image there in the shadows of the forgotten, if not of, ignorance.

I searched the interent for something about Marouf Al Rusafi in English and I found only one site:

from which I took the lines talking about Marouf Al Rusafi
“There is a very important tradition in Iraq of the poet as a symbol. For example, Marouf Al Rusafi was a poet who was seen by the Iraqi people as a national hero, because he was publicly against the British-imposed regime, against the monarchy. He went from being a member of parliament to a very poor man, selling cigarettes in Fallouja, being in need, without privileges.”

Her is my post

He took the book from my hands murmuring with interest: “what is this?”. He was a man sitting next to me in the bus. He started looking at the title and the picture.

I didn’t feel annoyed. He gave me back the book. Smiled. then he examined my face, as if wondering if I am angry at his movement. I was smiling. He said: “he was about to be the president of Iraq” . “and what happened?” I asked. “the English didn’t accept that”. I nodded my head with a sign which also means “I appreciate what you have told me”.

Marouf Al Rusafi lived in Baghdad in the first half of the 20th century. Between 1933-1941 he lived in Al Felluja in which he wrote his controversial book “Mohammedian Biography”.
He is known as a poet with a sardonic writing style. King Faisal refused to accept Al Rusafi to be a member of what was called as “first establishment board” of the early Iraqi government and the causes were, as King Faisal said: “…..due to his sexual perversions and living with prostitutes….”.

In this book I just bought entitled “the Iraqi message: in politics, religion and sociology” he talks about many things but what surprised me was his trial to show us the good side of some of those who are famous of not entering Islam at the time of the prophet Mohamed. They are regarded as “bad” and “evil” persons, but he was trying to show us some positive characters in them. On the other hand he was trying to show us the “bad” aspects of those early persons who accepted Islam as their religion at the time of the prophet Mohamed. These are holy people, but Al Rusafi did criticize some aspects of their behavior. And to my surprise no body hurt him much. It seems that people were respecting him in spite of that. I hope that there comes a day when we start again, in Baghdad, and in Iraq as a whole, to respect people’s views and ideas, whatever they would be, like our fathers and mothers were doing.

Monday, August 04, 2008

Dose of ECT

Electoconvulsive therapy under anaesthesia has just started in our hospital. There is a new aneasthetist who will come daily to our hspital to help giving the anaesthesia. I was confused by the new ECT instrument in this new hospital. It measures the dose by Voltage and not by millicoulombs. All the instruments I worked on before are with a milliCoulombs gauge always fixated on 225, which can be increased to 250 if the seizure doesn't start from the first time. I have only see one or two cases when we needed to increase the dose to 250 milliCoulombs, with one case we used also hyperventilation of pure oxygen prior to the second trial.

This instrument is with Voltages gauge fixated at 70 Volts. I tried at 70, and no fit happened. The nurse assured me that they usually increase the dose to 110 Volts. I remembered that I have visited the ECT unit before few days and asked the working staff about the dose and they told me that it is fixated to 110 volts. I looked at the gauge and noticed that its maximum reaches more that 110 by about three folds. So I decided it is safe to go to 100 Volts. And no siezure happened. I stopped the treatment trial and posponed it to after tomorrow.

I started searching the net about the dose of ECT (by the way, I remember a student in psychiatry, a colleague of mine, have asked a senior psychiatrist about the Dose of ECT, and she responded: Do we measure ECT in DOSES? go read that in your book!!!), and I found the following:

From the Wikipedia:
"Modern ECT machines regulate the current to keep it constant and thus the voltage may vary up to a maximum, typically 450 V, but is usually around half that level in most cases."

From a site (is it an antipsychiatry site?):
"a small electric current is passed through the brain and the voltages used are no higher than 150 volts." and "the smallest current is 0.75 amps, more than enough to kill if applied across the chest"

American Journal of Psychiatry. 134: 9, (September 1977): 1010-1013:
"ECT parameters were conventional. i.e. 130 volts for 0.3 seconds."

The Royal College of Psychiatrists advocate using dose titration to each pateint (individualisation of dose) and not using a fixed dose for everyone. There are some ways of titrating the dose according to age that is not clear to me yet.

A study published in the Psychiatric Bulletin (2000) 24: 184-187 of the British Jouranl of Psychiatry says the following:
"Clinical opinion is currently divided on what is the most appropriate method of determining the stimulus dose for ECT. A survey of ECT practitioners in the USA reported that 12% used fixed-dose strategies, 39% dose titration and 49% formula-based methods "

I know nothing, at time being, about dose titration, nor about formula-based methods. But as I continued searching I started finding some clues.

I read the following abstract of a study:
"Seizure thresholds, as measured by dose titration, varied fourfold among our sample and the average value was 105.5 mC or 16.7 J.". So we can conclude that we should estimate the seizure threshold by dose titration. It seems that dose titration means giving a low dose and see whether a convulsion will occur or not, it not we give a higher dose. Read what they did in this study regarding titrating the dose:
"At the titration session, 27% of patients had seizures after a single stimulation and 37% had seizures after two stimulations. Only one patient required four stimulations to induce a seizure."

So it seems that it is not harmful to give a dose that will not cause seizure? They continue saying :
"No patient had significant adverse events associated with the dose titration procedure. "

The `half-age' method, however, is still a mystery for me.

Friday, August 01, 2008

waves of speech

I went outside before electricity was supposed to be cut. I usually stay at home till the electricity is lost at 10 pm daily and I found myself suddenly in darkness. Today I went outside at about 9:45 pm and found my neighbours all sitting in a small garden. I joined them and the fun started. At first we started complaining at the hot whether. Then a neighbour showed me a video in his mobile of a fat drunk lady dancing in a very funny way. Then another neighbour came to tell us 2 jokes that really made us laugh from our hearts. Then we started talking about Baghdad and that it is much better than before a year. Two men started telling us about the old Baghdad. One of them asked "who say the film named ??????" i cannot remember the name. The man next to him said "Oh that was in the 1970s in cinema Gharnada" and they started remembering the film. Another man told us that one day his uncle beated him with a blow after being sad for an event he saw in the film of "Al Risala" and saw how Al Hamza had martyred. We all laughed. The joking guy started again a joke: " one day a very religious man had a familly....he didn't want his familly to watch TV because it is a devil work as he was saying....his wife suffered for years to let him buy her a TV but he said that she could only watch the film Al Risala when shown once in a year in some riligious ceremony (the film is about the begining of Islam)....she accepted....then they had children...children asked their father to buy them a video....he did but he brought them only one film....Al resala film....they kept watching it again and again for years....they grew up....then one day they asked him to take them to cinema...he took them to Al Risala film...when they were in the cinema watching, and in the screen there was Al Hamza above his horse running in the screen before the war would began...Al hamza took his sowrd and looked at the audience in the cinema and yelled: Ishlounak Abo Kareem?? (Ishlounak means how are you Abo Karem)"
We all laughed then started talking about Rashid Khayoun and his book "religions in Iraq" and one of them started talking about the Assurians and about the winged ox....and then a man brought us a soup...we ate from the same dish..with different spoons offcourse...
We were all tired and made some funny mistakes of concentration.. the most funny of which was when we were talking about Baghdad and one man suddenly asked us with a loud voice and some facial expression as if being lost: "do anybody of you know the number of ???????" he said a name of a person unkown to us... "Who is that?" one asked..."a translator" answered the questioning man... we all looked with confusion...when that man looked into my eyes I bursted into laughter and all started laughing....
I gained back my good mood....went back at home and started listening this song:

"Oh, qu'est-ce qui pique,ce hérisson
Oh,qu'elle est triste sa chanson
Oh,qu'est-ce qui pique,ce hérisson
Oh,qu'elle est triste sa chanson
C'est un hérisson qui piquait, qui piquait
Et qui voulait qu'on l'caresse, resse, resse
On l' caressait pas, pas, pas, pas, pas
Non pas parce qu'il piquait pas, mais mais parce qu'il piquait"

The music is gay and i smiled, but i don't understand the words at all.....

Emotions and Dopamine

Have you seen how emotions can prevent the manifestations of brain diseases. Robert De Nero plays in this film a case of parkisonian symptoms as a complication of encephalitis, and how one doctor find Dopamine to be effective. But after the first improvement in his case he deteriorated again. After this beautiful woman asked him to dance with her on the rhythm of piano playings, his tremor and other involuntary movements stoped, little by little....
The film name is "awakening" and it tells the story of discovery of Dopamine, a chemical substance present in the brain that affect our psyche and motor function (psychomotor function). Modulation of the level of Dopamine in the brain by many famillies of drugs helped to ameliorate many life disabling, if not fatal, diseases.