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
Suicidality

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.

A Day in an Iraqi Psychiatrist Life (part 2)

Yesterday was the last day of my break from work. I went to bed soon after the electric power was lost. That was at 12:45 midnight. It was hot. I woke up first at 6:00 am. I take a look at the clock. I felt how much my throat was dry. I tried to swallow but there was no saliva. I searched for the water bottle. It was hot water but it helped a lot. I decided that I sleep a little. I woke up at 6:45 am. I have some headache. Some neck pain too. Oooh I said to my self and walked drowsily to the refrigerator were I found a cold bottle of water. I felt better. Washing my face, taking on my clothes, putting the flash ram, a pencil, and money in my pocket I’m now in the street feeling that the sun’s light is so intense, so I contracted the muscles around my eyes. I took my first bus at 7:00 am trying to relax my forehead muscles which are already frowned, a thing that will cause me tension headache in an hour or two.
At 7:15am I bought a weekly magazine and took the second bus. At first it was so fast. The streets were not that crowded. I enjoyed reading about the history of Baghdad in the magazine. We reached that area. The road was blocked. Cars were stick one to another. We entered that irreversible crowd. Our driver tried to go back but he could not because of the cars behind us. We stayed that way for some minutes. Then cars started going back on the other part of the road. Our driver told us that there is no way he can made it to the place we were going to and that he will go back. I asked the driver whether I could walk for some distance and find another bus. He showed me the way. I went and it was so easy to find another bus, but it took me so long to reach another blocked road. But this time all the people left the bus silently and the driver started looking at me and told me: “this is it brother, it is blocked since one month!” I asked him how to reach my place of work; he took a pause and then told me to ask those men standing near that bus. I went to that bus, I asked them, they proposed that I take a bus that goes away from my working place then find a bus that goes to my working place. It was the only way. I made it. I took a bus, then a jeep. A jeep made in the 1930s or 1940s, with one sitting next to the driver, 8 in the back, and 2 or 3 stand on the back door. You know what? I was among those who stand on the back door.
So it took me 5 buses (4 buses and one jeep) to reach my job at 10:10am. I walked fast to my room to wash my face again. I took my white coat and went to where the committee must be now. It is Tuesday, and the forensic psychiatric committee is held to see the new cases and review the old cases. I was supposed to be there at 8:30, or at least 9:00 to see the new cases and write my notes before the committee is held at 10:00am. Anyway, nobody asked why I was late. They started there interviews. I listened and asked few questions. One of the new cases was a case of substance use disorder. He said he want Parkizol (=artane= trihexiphenidil). He repeated that. Then he started crying. The senior told him that it is ok. But he wanted it at the moment. Then all of a sudden he pulled a razor and put it in his mouth. He said: I will swallow it if you don’t bring me Parkizol NOW!!!!
We were all silent; only one senior was dealing with him. The police tried to help but all they did is just to make him more agitated. The senior asked them to be silent. They could not. The senior asked them to go. They did. The senior talked a little with the man who started crying profoundly. The senior asked one of the police men to come in, then the senior asked the man to give the razor out of his mouth to the police man. The man obeyed him. It was a lisson for me how to deal with theatrical patients and how to stay calm.
After that the senior next to me (there were 5 seniors today in the committee) asked me: Sami, what is the difference between school phobia, and truancy from school. It was an easy question. That senior loves me and loves to see whether I know things or not. He loves to ask easy important questions. I answered him. He said: Sami, you are good. At that moment I thought that my senior is just trying to raise my moral. To make me feel more confident. Especially after what that man with his razor did. My senior may had felt that I was tense. But why school phobia came into his mind? Well we can say that I’m a student in a school, and I may have some phobia especially after seeing such a man with multiple scars of self mutilation who threatened to suicide. Was that senior telling me that it is better to have a “school phobia”, like in my case, than to have “truancy from school”, like in that man with substance abuse disorder case? You may see those last lines silly but that was running in my mind when I was walking back to my room at 12:30 pm after the committee finished its work
I took my lunch at my work and it was: rice, a wing of chicken, yoghurt, and a half of an onion. At 1:30 pm I took the first bus back to my home. I reached my home at 3 pm exactly after another 3 buses that run so fast cause the streets were open this time. I took a bath. Oooh dear, I told my self, how beautiful life is! I put my head on the pillow for some minutes. Then took a thesis entitled “prevalence of depression in the physically disabled patients”. I thought about my coming thesis which will be entitled “prevalence of depression in psoriasis patients”, and wondered of the methodology I may use. It took me for about 30 minutes examining the tools of the methodology of the thesis in my hands. It uses the general health questionnaire-30 (GHQ-30), then used the ICD-10 structured interview on the positive cases of GHQ-30, then finally used the Beck Depression Inventory 13 to assess the severity. I wondered if that was necessary.
At about 5:00 pm, I took Michel Foucault book “history of madness” and started reading about the ship of fools. And I wondered wether the ship of fool is still existing in Baghdad symbolically.
At 5:30 pm water came back to my home. I started washing my clothes and dishes.
At 6:30 pm I took one of the psychopharmacology books to see whether there are long term side effects to the tricyclic antidepressants like a patient had asked me today. I told him that there is no need to worry but told him that I will look for the rare ones for him. I can remember I have read someday somewhere that there are reported cases of tardive dyskinesia due to long term treatment with tricyclic antidepressants. But I failed to find this note again today. I will look for it again before midnight in Companion to psychiatric studies because I think it was there were I read that thing. It must be that I read it somewhere but I want to make sure about it. After midnight I will go to the my sleep land to find some dreams waiting for me.

My Most Far Memories

Tri ru rum….ti ti rum…..am walking away….from the troubles in my life…am walking away…to find a better day….am walking away….

What a great song…..I think I will have some type of addiction on it. I’ve already had withdrawal symptoms from it. I came craving for it. And it seems that I need a more dose of it today.

The most far memory I have is that we were in a car. Me, my father, and my mother. My sister was not born yet. I must be below 4 years old. Cause when I was 4 years and a half my sister was born. Is it possible to remember that far? Anyway. I remember I was in the backseat. Fairouz was singing “A hadeer il bousta” in the car’s radio. We were near Baghdad international gallery between Al Hartheya and Al Mansour. In a corner there was a restaurant called EL NASAEM. In its garden there were colored circles of lights. Red, yellow, blue, green, and white. I liked them a lot. Now every now and then when I hear that song of Fairouz I remember those lights. My mother was young and energetic. My father was teaching at secondary school but at the same time he was studying art at evening. I asked them why we did not go to that restaurant. I cannot remember what they answered.
I cannot remember something else till am 5 years old. Me, my mother, and my aunt went to Jordan to unknown cause to me. We went to Al Aqaba beach. I knew Zina, a girl of my age. Her mother became my mother’s friend. They were alone. We became neighbors at hotel. I remember my mom said something about me loving Zina. I was so bothered and annoyed by that and told her that I only like her. The little Sami said something like: “Zina is just a friend…..A FRIEND….I do not plan to marry her mama”.
I remember, and am sure of that, I loved her mother. I was so embarrassed when they put me on the table and tell me to stand up there so that we took a picture. They surrounded me. My mother, Zina’s mother, and my aunt were standing around the table while am standing above the table. I refused to stand there. I object, but they did not listen. The little Sami said to himself: “they treat me as a child. Why they put me to stand above the table. Why don’t they stand above the table like me. Why they surround me like idiots. Even Zina’s mother is smiling. Am I short to be put on the table? Do they think they are more mature than me?”
I was so embarrassed that I still remember that till now. When they did not listen to my objections I became quite and looked at the camera with a faked facial expression.
I remember one day, before leaving Al Aqaba, my mother asked me to bring back the white radio with that red line in the middle of it from Zina’s mother. I went to their room. Their door was opened. I froze. Zina’s mother was sitting, with her back on the door, while the radio was behind her. I froze again. I cannot remember what she was wearing but I always ask my self this question: “for the God’s sake, what she was wearing?”. A question that is abnormally recurrent. I think her dress affected my little heart. I froze again and again like a statue. Till she, without turning her head, said: “sami, why you stop like that? Come here”.
I went inside her room. My memory tells me that something like this dialogue runs between us:
- Sami, I wanna ask you
- ……
- Sami, you will tell me the truth.
-……
- Do you love me?
- I came to take the radio.
- I know, but tell me, do you love me?
- My mother wants her radio.

I cannot remember what happened later. I swear I cannot remember.

Free Associtaion (part 23)

Terri rum tirum....tum tirum....terri rum rum...tum tirum...am walking away...from the troubles in my life.....am walking away...to find a better day....

This how Craig David starts. Am hearing it now. It was sent to me by a friend who has just reached the USA from Iraq. And the lyrics goes well with his situation. He suffered alot. He is a genius doctor. Hope he will find his better day there. Since I recieved this song and am hearing it repeated for hours till now. It took me away. How music can affect us so deeply? I think it was AL KINDIE who used music to treat patients before centuries here in Baghdad. I use music to treat my own crisis. I use it as type of crisis intervention. Does this mean that am in crisis now? No, am just in stress. In tension. I took a break from my work. A long one. And am already missing my job. Working seems to let me forget my problems. Is it right to forget our problems? Well...I don't know...Someone has just knocked my door. He is the same guy of yesterday. I never saw him. He says that he gave my father some money and he wants them back. My father don't remember this. Neighbors told me that this man made some problems before. Am affraid of him. As if all my problems were not enough to make this guy comes and disturbs me.After hearing this song many times it seems that I don't know what to do. Ok...I will go to one of my neighbours and pay this guy a visit. I wanna talk frankly to him. Ok let us do it....take care...

Fish’s psychopathology new edition

Fish’s psychopathology is our best text of descriptive psychopathology we use in Iraq. I have published a summary of the book in my blog before about 6 months. The previous edition of the book was published in the 80s. The new edition was published in 2007. It had many differences from the old one. Here are some of the main differences I found in the chapter of DISORDERS OF PERCEPTION. If somebody find it interesting just tell me so that I may continue searching for the differences between the 2 editions.

I will now enumerate the differences:

1st in the change of intensity of sensation we can find more examples: anxiety and depressive disorders, migraine, hangover from alcohol, and LSD ingestion lead to increase in intensity, while attention deficit disorder and depressive disorders may lead to a decrease).

2nd a change in the perception of the special form can occur in schizophrenia.

3rd there are three types of illusions: completion illusion, affect illusion, and pariedolia.

4th 3rd person and running commentary hallucinations have been described in mania (not only in schizophrenia).

5th there is a difference between Gedenkenlautwerden and echo de la pensee. In the old edition there is no difference between these two terms.

6th a newly mentioned phenomenon called PEDRE PIO PHENOMENON which entitled a pleasant olfactory hallucination.

7th mention of a new classification of tactile hallucination into 3 types: superficial, kinestethic, and visceral.

8th organic hallucinations part in newly written with the omission of hallucinatory syndrome of Schroder.

And 9th a new section on Body Image Distortions is added.

I didn’t go into the details of the differences so that if you interested you can go and see it by yourself. But I will be glad to answer any question you like to ask about the differences.

A day in an Iraqi psychiatrist life (part one)

It was in 2006 when I was working in Baghdad general hospital as a resident doctor in psychiatry in the psychiatry ward. Patients were very few in number. Cause Baghdad was not a safe place to live in. People were leaving it. It was late in afternoon when that lady came into our ward accompanied by her sister. Both were frightened. The lady’s eyes were widely opened while she was walking aggitated searching for someone to speak to. Her facial expression was that of a weeping woman, yet no tears seem to come from her eyes. It seemed that tears refuse to come. When she saw me she just started breathing deeply and making sounds of crying with no tears and her sister started talking telling me that her sister didn’t sleep for the past three days. I looked at the lady’s eyes. They were tired. Surrounded by black/bluish/reddish halos. Her sister added that the lady is from Dyala, and that she came to Baghdad with her 3 sons before 3 days to live with her sister cause Dyala is no more safe to live in. I told them that if they agree we can sit and talk. The sister looked at the lady and told her that she want to go home to be next to her family and the lady’s 3 sons. The lady turned to me and asked me with her widely opened eyes if I can admit her to the ward. She added that she doesn’t want her sons to see her in this unstable state anymore. In less than a second, without thinking, I agreed that the lady was in need of an admission. It seemed that that didn’t need thinking. It needed emotions. It needed empathy. I show them their room. And left them for few minutes. The sister came out and asked me to take care of her sister. She told me: she is your sister doctor, take care of her, she had suffered a lot. I answered: off course she is my sister, no need to worry about her, just keep in touch with her by phone ok?
The sister answered: sure doctor, I left her my mobile phone so that she can contact us. Then added: do you need my husband mobile phone number so that you call him if something happen?
I said: no, she got your number, that is enough.
She thanked me and went. I approached the room where the lady was. She was sitting there so frightened. I greeted her with a smile and told her that she needs to calm her self and control her breathing. “you don’t need to be frightened here, you are in the hospital”. I asked her if she had eaten her lunch. She said she did. I told her that I will interview her in 30 minutes.
After 30 minutes I went to interview her in her room. She was still shivering. I asked her about the problem. she started to talk fast & aggitated about what happened in the area she lives in. She wittenessed many violent acts. She was talking while she was having shorness of breath. I let her talk. I still remember what she told me. I even developed some posttraumatic stress symptoms when I heard her story. Actualy stories. But what I want to say here is that when she ended talking and she was shivering so severely I asked her:
- You seem so affraid now.
- .....
- you are in the hospital now, here with us, does that make you feel more secure?

As I ended my last word, a loud explusion burst just next to the hospital, all the windows and doors made echos, and then, nearby bullet firing aggressive sounds started entering our frightened ears....
We both stood up and run to the corridor. She sat on the floor with her downcasting gaze and terrible shortness of breath. I felt speechless. I told my self that she is safe in the corridor more than in her rrom which contain many windows. I was so speechless. I took a deep breath.

My Father's Paintings

After I published that post entitled "wadi3 il safi" my father send me these new paintings he made lately.

Sumerian Friendship

As a child at primary school I was amazed by those simple, easy going, spontaneous, highly energized students in my class who were all relatives. There were about 8 of them. We were about 40 students in my class. Those 8 relatives, 4 male and 4 female, were the poorest ones. It was evident for me from their bags, and clothes. They were so happy. Maybe the happiest among us. It was clear for me that other students avoided them. Every two of us shared one desk. I was sitting with my friend A on the first desk near the blackboard. Behind us sat three sisters on the same desk. Those three were part of that avoided group. I still remember one of them who was playing with me a game. She used to knock on my back when the lesson started. When I turn around at her she was always just smiling. I liked her. All those avoided relatives were poor, I guest at that time. That was evident from their clothes and bags. They have more dark skin than most of us. My friend told me not to play with them. I asked him why. He said they are people living near the small river (a small canal of water came from the main river Tigris), and their job is to serve other rich people by caring for their animals. He said to me something like: they live with animals, don’t play with them. As a child in my first year I followed cautiously my friend’s advice. He used to give me video tape of Bruce Lee, and some rare cartoons. And I never knew from where he brought them. I think it is because of those video tapes he used to give me I was looking at this guy as someone with greater knowledge than me. He was also the one who taught me the slang names of the genitalia in Iraqi language, and that was much appreciated by me at that time. So I followed his advice. But deep inside my heart I loved them. I was more eager to be close to them. But at the time I tried to make that into action it was clear for them that they were avoided, so they closed the door, not so tied, against my approaches. The three sisters behind me all avoided me. I was just a kid. I didn’t have the capability to open those doors again.

During my teenage years I started having ambivalent feeling to those who lives on earth, as I like today to call them. Those who can walk bare foot. Those who can know what the whether will be the coming day just by looking to the sky. Those who know the stars and their places and names. Those who know about trees, insects, animals, & agriculture in their special way. They learn by observing nature. The got a heritage from ancient times of their special knowledge. You can rarely find a book talking about their knowledge, cause unfortunately most of them don’t have time to learn read or write.

I remember that elderly male cleaner in the that hospital in which I was working in 2003. he was so proud of his self. Actually he was arrogant. He got a policy that says: I know my job, I don’t want anybody to talk to me! I asked about his family, and his background. They told me that they are very poor, living in houses made of mud on the city borders, and that his family take care of animals of the rich people. He used to sit in my room, on my chair. He was old. I was so young. When I enter my room in the ward, found him sitting on my chair, behind my table, I usually get confused what to do. I greet him then act as if there is something to do around the room. Either looking into the plants, counting the files, act as if reading from a paper, or at least looking through the window. That malingering is just to give him time to leave my chair and table. My room door was always open and I never thought of locking it. But his behavior was really making me tense a little.
The war of 2003 started. Nobody was forced to come to work. Most of workers went to their homes and never came back till the war ended. Me and three other doctors volunteered to work. I was working every night from 10 pm till 8 am. That arrogant worker was coming almost daily to his work. He sometimes sleep in the hospital. I was spending the nights in the ward and the nearby emergency room for pediatrics. Sometimes he spend the night with me. He never talked to me.

One night I was exhausted. I was supposed to do an exchange blood transfusion to 2 babies having jaundice. In the operation you got to take 20 ml of blood from the baby, through it in a waste bag, then take 20 ml of fresh blood from the blood pint and inject it in the baby. And you repeat that for about 25 times. I called a colleague so that he works in the emergency unit while I do the exchange. There was no nurse to help. I asked one of the babies relatives to help me and he did well. It took us about 1 and a half hour and it was ok. The second’s family members were so emotional. They could no offer help I thought. No one to help, I decided to do it alone (my first dangerous mistake). I started. Took 20 ml of blood from the baby and injected it into the waste blood bag. I forgot to give him the 20 ml fresh blood. I took another 20 ml of blood from the baby and through it in the waste bag again. Do that for another 3 times. In total I took 100 ml of blood from the baby and through it away. Then. Oops. My God. The baby was ok but I was about to die from fear and shame. I started sweating. Little shivering. I hold the syringe and started taking fresh blood and injecting it into the baby slowly. I monitored his vital signs. It was ok. I gave him the 100 ml of blood. Then called that arrogant cleaner and asked him to call the doctor working in the emergency room. He did. I told the colleague doctor about what I did. To my surprise, that colleague became so angry at me and shouted at me something then pushed me toward the door and told me to go to sleep.

The arrogant cleaner saw all that. I sat speechless in the nearby emergency room. There were maybe 2 patients receiving treatment. No patient came till my colleague finished the operation. The arrogant cleaner was passing every now and then next to me looking into my face. I did not give him eye contact as I remember. The colleague came back. Told me that everything is ok. He added that he was sorry for what he did and that he wanted me to go to sleep. I nodded my head and go walking slow to my nearby room. Next to the door of my room I saw that arrogant cleaner sitting on a chair, not mine. He stood up. I passed. Sat in my room. He sat on his place. I wondered why he stood up. Was that to show me respect? I asked my self. I stood up, drag my chair outside the room and put it next to him. and this dialogue run between us:
- How are things? (I said)
- Good.
- Do you have a cigarette?
- Um…ahh…a bad one.
- Bad?
- I mean a cheap one.
- Sumer? (Sumer is an Iraqi cigarette trade mark)
- Sumer Abu Il Chees (means those one that sold not in a packet but in a paper container).
- I like them give me one please.
- Here it is doctor.

He smiled wide. Gave me one. Took one for his self. With his lighter he approach me to lighten my cigarette. Then his. We took deep breaths. Outside were some sounds of explosions. And from that moment we became close friends.

Erbil

Akavo klah


One of the oldest cities in the world. It had been mentioned in Sumerian writings as Erbilium . Now it is the capital of the Iraqi Kurdistan.

I never visited Kurdistan before. Till this April when suddenly I got an unbelievable opportunity to visit it. I was so happy to see all these Kurdish people with their characteristic costumes, music and accent in speech. I even knew some Kurdish psychiatrist and one psychotherapist. Their names weren’t that easy for me to remember at the first time, but after few days I found it so easy and so beautiful. Their names got some musical tone that is really characteristic.
Erbil is called by Kurdish people as Hewler. Hewler means “the place of the sun” as I can remember somebody told me. When I knew its meaning I remembered that this city got a rich heritage full of civilizations and religions. Some old religions in the area worship the sun, or regard it as something holy. From those old believes, I think, came the name.

I went to the old castle. I took many photos. I was unlucky in that the most beautiful photos were damaged during transferring them from the camera to the computer. The rest are not my best shots but they were wonderful cause Hewler is wonderful. Hewler got many secrets and untold stories. It wasn’t enough for me to get close to it. I spent just 5 days there.
But am happy I visited a part of Kurdistan at last. Hope in the future I can visit more.

These are some photos. The music accompanying them is a traditional Kurdish music called “Akavo klah” played by the great Iraqi Auth (3ud) player Muneer Basheer.

Thank You Tracy

I still remember that day in Mosul. It was Saturday. I was usually on call every Thursday, Friday, and Saturday. While all my colleagues were in their wives’ arms, me, the single, work on the weekend. It is known to me that during weekends the mentally ill relapses. So I was really annoyed every weekend.
It was Saturday. I did not shave. Why should i? all my patient are neglected. My ward is neglected. It was weekend so I neglect myself. I went walking on that corridor. Dr. P was walking on the corridor on the opposite direction. I noticed before that he doesn’t like me. He never greeted me before. I never let myself hate someone. But this one with his long beard, was challenging my emotions. When we came to be near each other in the corridor he smiled to me. How strange. He even greeted me. I suddenly felt that I like that man. I greeted him and walked stunned. Dr. Y was in front of me suddenly. He also did not greeted me before. But today he nodded his head for me and greeted me. I smiled to him and greeted him and it was really strange how I found my self I like these 2 men.
The working day passed quickly. I went to the library to find a book. But the librarian said:
- Dr. P told you?
- What?
- So Dr. Y told you?
- Told me what?
- How did you know then?
He said that and gave me a big envelope from USA, it was heavy and it I read the name, it was Tracy. Wow. She sent me the books I need. I went happily to my room. Open it. And it was a magnificent 4 books. I felt so happy. I shaved my beard. And I start reading from this book then change to the other and I was really a happy. When I went to sleep that night I said to myself: “ohh! I knew why Dr.P and Dr.Y greeted me this morning!”

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…

Manie Sans Delire

Making a diagnosis of PERSONALITY DISORDER is difficult. The validity of such diagnosis is controversial lately. It was claimed by some that a diagnosis of personality disorder is ready to be given by a psychiatrist to all those whom he/she dislike. Me myself and one of my dear colleagues, at the beginning of our first year of residency in psychiatry, used this diagnosis against each other while we have problems with each other. We used this diagnosis as a type of hurting. As a type of revenge. And believe me it was very annoying and really hurting and have long lasting effects. Till one of the older residents in psychiatry told us to stop this childish behavior which, as he said, IS DANGEROUS AND UNETHICAL. But some personality disorders are less controversial than others. It is estimated that 10-14 % of the general population meet the diagnostic criteria for at least one personality disorder.

The antisocial personality disorder is an old concept in psychiatry. In 1812, Benjamin Rush introduced the concept of MORAL DERANGEMENT. In 1835, Prichard introduced the term MORAL INSANITY. It was Pinel (1801/1962) who coined a term that I like, it was MANIE SANS DELIRE, which means MADNESS WITHOUT CONFUSION OF MIND. I like the term, first, because it is in French, and when you use it the other will think that you are a highly cultured person. And Second, because it defines itself.

Nowadays, the DSM IV criteria of antisocial personality disorder can be easily remembered using the mnemonic CORRUPT:
1. Conformity to law lacking,
2. Obligations ignored,
3. Reckless disregard for safety of self and others,
4. Remorse lacking,
5. Underhanded (deceitful, lies, cons others),
6. Planning insufficient (impulsive), and
7. Temper.
(3 of these seven are required to be a trait of the personality for life so that the diagnosis is made, and it cannot be made under 18 years of age).

Psychopathy was related early in the formulation of the concept to criminality. Not all psychopaths are criminals. Henderson (1939) described CREATIVE, INADEQUATE, AND AGGGRESSIVE PSYCHOPATH, citing Lawrence of Arabia as an example of creative psychopath.

What am up to is to state that I think that Silvador Dali was having an antisocial personality disorder. As a child he used a sharp instrument to wound the cheek of a goat and, used its blood to write his name on its face. He also pushed a friend of him for a bridge after he made sure that no body is watching, and he confess in his memo that he did not felt any remorse. He also kicked his sister on her head while she was crawling. At school he jumped from above the stairs to cause alarm and apprehension in pupils faces, and to seek attention. He repeated his jumps, from higher and higher points and he got many wounds and bruises, but he said that it was ok because he aimed to seek their attention and fright and he succeeded.

During his life as an adult you can find many evidences for his impulsivity and temper, for his break of social norms, and recklessness.

His indulgence in painting can be explained by this statement from Fish’s psychopathology when describing the antisocial personality disorder:

“As the boredom threshold is low, these individuals resort to thrill-seeking
behaviours such as substance misuse, gambling and promiscuity”.

And I will add to those thrill-seeking behaviors: Art. Especially the unusual art. Artist are highly imitated by many. From here comes the danger of imitating a person with mental illness.

Thought form Vs. thought content

I think that Bou Jidra is writing as if he dreams. Also Silvador Dali had drawn his paintings as if he was dreaming, to jump above the obstacle of repression, and declare the naked truth. Regarding the way that we, students of psychiatry, study thinking, we divide a thought into a content, and a form. In Fish’s psychopathology, our best text of psychopathology, there is also disorder of the stream of thought (tempo and continuity). Schneider suggested that there were three features of healthy thinking: 1. Constancy: this is the characteristic persistence of a completed thought whether or not it is simple or complicated in its content. 2. Organization: the contents of thought are related to each other in consciousness and do not blend with each other, but are separated in an organized way. 3. Continuity: there is a continuity of the sense continuum, so that event the most heterogeneous subsidiary thoughts, sudden ideas or observations which emerge are arranged in order in the whole content of consciousness. The patient last week, Mr. F, when interred the ward, started playing sport, some patients joined him. He refused to stay one day unshaved, some patients joined him. He made a list of things he wanted the hospital to provide for him. On of the seniors said: some people with formal thought disorder may have beneficial thought contents. That saying by that senior, sparked contradictory thoughts in my mind, I argued my self again and again, sometimes am with what he said, sometimes am against it. As an ordinary academic student of psychiatry, I got to be against what he said. But. I remembered how I was always confused about what some artist do. Let us take for example, Rashid Bou Jidra, an Algerian novelist, and a writer of scenario also, one of the scenarios is that for the film of L’akhthar Hamina: sineen il jamr. Bou jidra, write long novels, with sometimes a complicated form, to a degree that I can say, with a type of formal thought disorder. But it carries a content that is full of meanings. Of surprises. Of lights focused into dark dots in our consciousness. Bou Jidra, himself, was admitted once to a psychiatric hospital. He wrote about that experience a novel called “el ra3an” . many of his novels talks here or there about an admission to a psychiatric hospital, or being mentally ill. If we talk about dreams, it is full of formal thought disorder. But reality in dreams sometimes is so deep, so intense, more than reality in awakening. We can find in dreams that we don’t like this person, or we are afraid from this trip, a revelation that appears in dream, but it hides itself in awakening. I think that Bou Jidra is writing as if he dreams. Also Silvador Dali had drawn his paintings as if he is dreaming, to jump above the obstacle of repression, and declare the naked truth.

DIGFAST

He entered the room. He is a man in his 50s, wearing jeans, his hair is long and white. His hair was so long for an Iraqi. His hair touches his shoulders. He was so proud of it I think, cause as he sit, he took out his comb and start searching for a mirror. He did not find any. He looked at the window. It was of some help. He combed his hair. When he ended, I opened my mouth and said:
Mr. F, am doctor Sami, I knew that you are new here, I came to see you, to see what did happen that brought you here, and I would like to help you.
He said: first, I need to have a glass of water.
I brought him one. He thanked me. Then asked me: in what year did you graduate from college?
I answered: 2002. and I never said anything else for the coming 30 minutes.
He then started to talk. I cannot remember what he said but he started talking and he never ended. He shifted from one subject to another. I did not stop him. I managed to found that he had the DIGFAST (Distractability, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, & Talkativness. DIGFAST is a mnemonic to remember the DSM IV criteria for mania). I wondered how long he would continue talking. He was taking few sips of water every now and then when he felt that his throat is dry. The glass of water helped him to continue. He talked about Jean Paul Sartre, Selvador Dali, and many many others. He talked about philosophy. About sport, health, politics, Marxism, Islam, and many other things. 30 minutes passed so fast. I looked at the watch, it was 11:45 am, I opened my mouth and said to him: Mr. F, I have only 15 minutes left with you, and I want to ask you about something, told me about your sleep.
He started to lecture me again about health, sport. I opened my mouth and said: and your sleep? At that point he felt angry at me. Told me that am trying to control him. I made up my diagnosis then let him talk again for the 15 minutes then asked him my final question on that first interview: am afraid I got to go Mr.F. I stood up, he did not. I start walking slowly and asked him: we will see each other in the coming days more, is there anything I can help you with at time being ?
He answered: I want a white paper to draw you something.
I gave him 2 and went, telling him that I will see his drawings next time we met and that would be after one day. The second day I went to the ward. The senior had discharged him. He was no more there, but he left me this drawing (see above the picture with the arabic writing; the other picture is a picture of a face who seems depressed, my diagnosis was BIPOLAR DISORDER, did the sad face symbolise his depression? and why a female? is this related to his long hair? did he wish to be a female? many questions I didn't ask)


The writing in the first picture is from the holy Quran, and it says: noon, (noon is the name of the letter N in Arabic), I swear by the pen and what they write in lines, by the wealth of God you are not crazy. That was a very poor translation by me, it got a very nice musical rhyme when it is said in Arabic, the sounds will be different, I will write it with English letters to imagine the music of these words: noon, wal kalami wa ma yasturoon, ma anta bi nimati rabbika bi majnoon.
bove)