The Last Psychiatrist

Don't Settle For The Man You Want

2010-02-08T15:59:02Z

I stopped reading The Atlantic when I wanted to stop cutting

]]> The Atlantic, writes Marry Him!, and describes a problem so pervasive and urgent it's hard to imagine Obama hasn't cleared his desk: what's an "independent," "feminist," "heterosexual" 40-something "woman" with a sperm-donor child to do when she can't find a man to marry her?

My advice is this: Settle! That's right. Don't worry about passion or intense connection. Don't nix a guy based on his annoying habit of yelling "Bravo!" in movie theaters. Overlook his halitosis or abysmal sense of aesthetics. Because if you want to have the infrastructure in place to have a family, settling is the way to go.

Oh, that Lori Gottlieb, she's a kidder. But she's not kidding.

There's a few ways to go with this, but here's a start: where is she finding all these idiots who yell bravo or have bad breath or poor aesthetics, or is this all the same idiot? If you're 0/3 in a single paragraph, you need to consider the problem is you.

To be fair, my conceptualization of what a good relationship is may be very different from hers. Here's hers:

In my formative years, romance was John Cusack and Ione Skye in Say Anything. But when I think about marriage nowadays, my role models are the television characters Will and Grace, who, though Will was gay and his relationship with Grace was platonic, were one of the most romantic couples I can think of.

Nothing characterizes The Dumbest Generation Of Narcissists In The History Of the World better than using throw away cinema as a template for life. What kind of results did she expect?

She thinks that Will being gay is an unfortunate coincidence, but it is actually the primary thing she wants. She wants a gay man not because she likes them gay, but because gay men aren't real to her, they're props. She wants someone who will see her the way she wants to be seen and fulfill various other roles she has planned for him, leaving herself free to "grow." It's hard to get that to happen when his Staff Of Unreasoning and Hyperbole is pressed up against her coccyx while she's trying to go to sleep.

II.

That Will & Grace speaks to her is completely by design. The producers tweaked that show specifically for a certain demo, i.e. her.

In its first miserable failure of an incarnation, it was called Ned & Stacey, and it paired Debra Messing with a good looking, heterosexual, womanizing rich guy. Everything else was the same. Here's the opening theme:

Ned: Why Stacey?
Stacey: Why Ned?
Ned: It was business.
Stacey: Strictly business.
Ned: Here's the deal - to get a promotion, I needed a wife.
Stacey: To get a life, I needed his apartment.
Ned: So what the hell, we up and got married.
Stacey: The only thing we have in common? We irritate each other.
Ned: Right! Enjoy the show.

The show lasted one season. No woman could relate to his, no woman would want this, only this. But make the main character gay, and you have a fantasy scenario: materialism and safety, but the emotional freedom to constantly reinvent and reaffirm yourself. The show should have been called, "The Non-Judgmental Dad I Never Had" or simply "Let's Pretend." But I'm not in TV.

III.

There are really two questions: the first is where Lori Gottlieb went so wrong, and the second is why The Atlantic thinks this is a legitimate posture.

A short excursion through Lori Gottlieb's prior life is illustrative.

Her first book, in 2001, is about her experiences growing up to affluent but shallow parents (her description) in Beverly Hills in the 1970s. Pause for effect.

This is what the Amazon blurb says:

In the image-conscious world of 1970s Beverly Hills, 11-year-old Lori knows she's different. Instead of trading clothes and dreaming of teen idols like most of her pre-adolescent friends, Lori prefers reading books, writing in her journal and making up her own creative homework assignments. Chronically disapproving of her parents' shallow lifestyle, she challenges their authority and chafes under their constant demands to curb her frank opinions and act more "ladylike.

Many of you may sympathize. What's a budding intellectual, not to mention future NPR contributor, to do in such a dystopia? Answer: she decides to become anorexic.

Somehow this has been characterized as a struggle with anorexia but you'll have to take my word for it: this is a struggle with anorexia the way Girl, Interrupted was a struggle with inadequate access to healthcare. It's all blamed on her parents, and secondarily on her social group. This is from her website:

"Of course they aren't overweight," Lori told her psychiatrist when asked if she thought the girls at school who diet are overweight. "Didn't I already say they were popular?"

Before you call Bill Cosby, consider that this kid is having a conversation with her psychiatrist. In the 1970s. Whatever you may think about the overpopularization of psychiatry today, there was a very specific demographic of kid that got to talk to a shrink in the 1970s, and that demographic is now in their 40s, unmarried and writing articles for The Atlantic. If you think there's no connection, the Amazon.com suggests you may also enjoy The New Yorker.

IV.

The mistake is to take the writing prowess Lori (now and at age 11) has and assume it mirrors the quality of the ideas. The writing is good (there, I said it) but the idea set is dangerously, catastrophically wrong.

Her next book, Inside The Cult of Kibu, was about her experiences at a failed dot.com. This is the introduction:

In the Spring of 2000, Lori Gottleib was lured away from Stanford Medical School to become the editor-in-chief of Kibu.com.... but after her comically unceremenious "unhiring" three months later...

Work through the timeline. This book was published in 2002. Stick Figure was published in 2000, which means it was written before 2000, i.e. while at Stanford Med. Meanwhile, she's hanging out at Whole Foods (not a joke) and joining Kibu. Then she's fired. So she hastily put together another book.

You can imagine this is how she dates. No direction, no sense of self, just jumping from one scheme to the next, trying on different identities. She actually laments how, while a med student, she was surrounded by more dot-commers than doctors. At parties they wouldn't think her interesting enough as a med student; but when she signed with Kibu, she

heard myself saying, "I'm on the cutting edge! I'm going to influence an entire generation!" Part of me even believed this.

Your problem is you believed it. My problem is you're right.

V.

A reasonable question might be, what kind of a man is this woman looking for? I defy you to answer this question. She's two books and at least three essays into the topic, and still I have no idea. What I do know, however, is what she's not looking for. That's where her laser focus is pointed.

She titled one essay, "5 Traits In A Mate That Are Not Deal Breakers." Take a moment to ponder the construction of that title. If I wrote an essay, "5 Things You Can Do That Won't Make Me Stab You In The Teeth" how many condoms will I end up using? You might counter with history: she was having trouble with mates before she wrote that essay. True, but you know that the type of person who would think to write an essay like this one reveals herself in other ways as well.

I've never believed that we should stop looking for Mr. Right (we shouldn't!) - but I do think that by changing our rigid idea of who Mr. Right is, we're more likely to find the right Mr. Right. You can't just order up the perfect husband á la carte - I'll take a little of this, a little of that, less of this and more of that. A guy is a package deal, as are we. Recognizing that isn't settling. It's maturity.

I actually had to pull my car over to the side of the road when I read this. This woman is in her 40s. And she has a kid. What the hell did those halcyon hours at Stanford Med do to her?

...having found myself still single at 40, I'd come to an eye-opening realization: Had I known when I was younger what would make me happy in a fulfilling marriage, I would have made very different choices in my dating life.

This woman should have a scarlet "ME" on her shirt. What makes me happy? What do I want? You can't run a relationship this way, you can't run a life this way. But the longer she stays single, the more self-absorbed she becomes, the more she thinks about what she needs and wants.

It's almost unnecessary to list the 5 Things About A Man Lori Is Only Pretending Not To Care About, but here they are anyway: 1. His height. 2. His Match.com profile. 3. His occupation. 4. His age. 5. How he compares to "my type." None of those are jokes.

Indeed. I ended up falling hard for a 5'6", balding, bow-tie-wearing guy I almost didn't e-mail on Match.com. He wasn't who I had in mind, but he was who I wanted to be with. And that, of course, is the thing that matters most.

Indeed, indeed.

VI.

Back to the article. There's absolutely no chance any woman will benefit from reading this article; I'd argue that it would only make her impossible to be in an elevator with, let alone marry.

I referenced Will & Grace, above, but the real star of the article is Sex & The City. This article is written about, and for, Carrie Bradshaw.

It's equally questionable whether Sex and the City's Carrie Bradshaw, who cheated on her kindhearted and generous boyfriend, Aidan, only to end up with the more exciting but self-absorbed Mr. Big, will be better off in the framework of marriage and family. (Some time after the breakup, when Carrie ran into Aidan on the street, he was carrying his infant in a Baby Björn. Can anyone imagine Mr. Big walking around with a Björn?)

She doesn't get it, at all. Are you asking whether I could I imagine a big producer, like the one that Mr. Big is based on, carrying a baby? Sure, why not? Or do you mean a guy like Chris Noth, the actor who plays Mr. Big? He just had one, so yes. Or do you mean...?

Meanwhile, the real Carrie Bradshaw (Candace Bushnell), the actress who plays her, and heck, even the character Carrie Bradshaw, are all in solid relationships exactly opposite to the ones she is looking for.

Mr. Big wouldn't carry a baby because that's the character. If you're looking to hook up with a two-dimensional character, you get what you pay for.

VII.

Gottlieb figures that because she's attractive and intelligent, the problem must be her standards are too high. Wrong. The problem is she is daring someone to like her. She has a Match.com profile-- fine-- but meanwhile, she publishes articles that say things like, "I'm at the age where I'll likely need to settle for someone who is settling for me." How do you like me now! "It's not that I've become jaded to the point that I don't believe in, or even crave, romantic connection. It's that my understanding of it has changed." Who's up for role-play? You think I'm pretty? Bam! Now I have a kid! What do you think of that?

All of this is what an adolescent girl might do, who puts her worst features front and center. She's not sure her best features are going to be good enough, but if you can like her despite the bad ones, then you must be The One. (Never mind that immediate next thought will be, "what kind of a loser would like me?")

All of this is a game to elicit a specific response from the man: "oh, baby, those things don't matter to me because I know that's not who you are, I know the real you."

The guy is irrelevant. As long as he delivers his lines, on cue.

VIII.

You may wonder why I am focusing on The Atlantic article and not the book that just came out, Marry Him: The Case For Settling For Mr. Good Enough. First, I didn't read the book. HA! Take that, college reading list.

More importantly, a book contaminates only its readers, but an article in The Atlantic makes it ok for intelligent people in general to think like this. That makes her wrong ideas dangerous.

You want something uplifting, so here you go: you can never have a good relationship with anyone when your focus is the relationship. There's a human being there who existed well before you got to them, and they weren't built for you or your needs or your parents or your future dreams as an actor. If you want to be happy with someone then your body and mind have to instinctively adapt to their happiness. If you're not ready for this kind of sacrifice, then you're simply not ready.

How Seroquel XR Works, Part 1

2010-02-04T17:49:26Z

When evidence based medicine results in a government sanctioned lie.
]]> 1. What is the clinical data on Seroquel's efficacy as an antidepressant?

In order to get an indication, the FDA requires at least 2 randomized controlled trials. Both were identical in design, and nearly the same in outcome.

Patients who were on an SSRI or SNRI, who were not improving after 6 weeks, were randomized to the addition of Seroquel XR 150mg/d, 300mg/d or placebo (along with the maintaining of their previous antidepressant at previous dose.) The results:

On the basis of this, and the other similar study, the FDA approved Seroquel XR as an adjunct to other antidepressant in MDD.

2. Is this a function of its antipsychotic properties?

No. At 150mg/d there is very little D2 blockade; and not all antipsychotics have been able to show efficacy as an adjunct in MDD. Some other mechanism is likely.

3. How is Astra Zeneca and the FDA explaining the efficacy?

Not an easy question to answer. Any proposed mechanism must be accepted by the FDA; once a mechanism is proposed and placed in the package insert (and promotional materials), it cannot be changed without resubmitting to the FDA-- even in the face of contradictory proof. For this reason, e.g. they are vague on the mechanism in schizophrenia:

All of Seroquel XR's promotional materials, the package insert, and the clinical trials describe the efficacy as the result of Seroquel's effect on norepinephrine and the NET.

4. What is the evidence for the proposition that Seroquel's antidepressant effect is mediated by norepinephrine?

Quetiapine is partially metabolized to norquetiapine. Any pharmacologic (i.e. receptor) description of the Seroquel's effect must therefore include norquetiapine.

Quetiapine does not bind to the NET; but norquetiapine, its chief metabolite, is a potent inhibitor if it. Tricyclics, Effexor, and Cymbalta all have considerable NET inhibition as well. It's logical to conclude that when you eat a Seroquel, and it gets metabolized to norquetiapine, that it would then exert some action on the NET.

5. At a clinically relevant dose of Seroquel, how much norquetiapine is there?

Not much.

The package insert states:

The Cmax and AUC of norquetiapine are about 21-27% and 46-56% of that observed for quetiapine.

Or, graphically (from Winter J Child Adol Psychopharm 2008):

Levels of norquetiapine did not differ IR vs. XR.

6. What amount of NET inhibition occurs at 400ng/ml? Show your work.

300ng/ml= 300ug/L

300ug/L= 0.0003g/L

MW norquetiapine = 803.11

0.0003g/L x 1 mol/803.11g = 3.7e-7M = 370nM

Norquetiapine's Ki for the NET inhibition is between 12-35 nM, depending on in vitro or in vivo.

At clinically relevant doses, the NET is more than completely occupied.

7. Wow, really?

No, not really.

It appears that, in contrast to the longstanding paradigm of post-Kohut modern psychiatry, there is more to the human body than serotonin and norepinephrine receptors. I'm as terrified as you are. I don't know what to believe anymore.

A study measured the NET occupancy to Seroquel and norquetiapine (administered independently) in monkeys after a single dose. Norquetiapine produced 80% occupancy of the NET at low concentrations.

However, in the nine suckers induced to participate in this other study, 300mg Seroquel XR for 7 days generated 300nM concentrations of norquetiapine (as predicted above) and 35% NET occupancy in the thalamus. 150mg Seroquel XR-- the dose at which it functions as an antidepressant-- resulted in 19% occupancy. That's not very much.

Consider that if Seroquel is metabolized to norquetiapine in monkeys as well, then a clinically relevant dose of Seroquel should produce clinically meaningful occupancy of NET (by the effect of its metabolite.) It didn't.

The actual occupancy of the NET after 300mg Seroquel XR is quite low, 150mg even lower.

8. Can you compare this to the occupancy of something I know-- like Effexor?

NET PET studies aren't as easy to do as DA studies, because many of the ligands used in the experiments bind nonspecifically and produce greater background binding. There's also not an obvious negative to compare it to (e.g. there aren't any DAT in the cerebellum, so that becomes your control in DAT experiments.) Radioligands specific for NET are only recently becoming used; Effexor doesn't have available PET data because now that there are such ligands for use in a study, Wyeth doesn't exist to pay for them. Take that, unbiased research.

Understanding that the comparisons are not entirely fair, a blood assay in depressed humans found that after 8 weeks of Effexor 150mg, NET inhibition was 50%. At 375mg, it was 60%. Paxil, an "SSRI", blocked about 30% at 75mg. Note that Effexor is only 55% protein bound (Seroquel is 80%) and thus in a real patient, there is more free Effexor to exert activity on the NET, which may be why it has such a larger effect on the NET despite a theoretically weak Ki (2200nM).

Despite this, the NET occupancy of a clinically efficacious dose of Seroquel XR (150mg) is likely too low to be the main cause of its antidepressant efficacy.

Part 2 in 24-48 hrs.

Check Out My New Acura-- ads?

2010-02-01T14:57:46Z

this is not an Acura ad

]]>
I send my partner a note: "Check out my new Acura ads!"

Acura is having a 24 hour promotion to coincide with the release of its new car, hence the ads you see today on my site. The ads mean money, of course, but I sent the note with some pride.

The ads signify a form of success, that my blog is Acura-worthy for advertising. Never mind if that's true-- that word "signify" indicates something else going on: I'm judging the quality of the site by the ads on it.

I've never judged a person by their actual car, because I'm hyperconscious of product branding and message, I am always alert to the deception. But here I am using the ad itself as a signifier.

Subtle flash animations, good photography or design, and of course the product in the ad-- all these things are signals to me about the site that has them. Of course, the ads mean different things to different people-- Acura ads may symbolize a sell out, or out of touch-- but the point is that the ads themselves, not the car, symbolize something. And what it symbolizes is: this company endorses you.

Many sites like mine have google ads, which only "pay" if you click on them; hence, they pay very poorly. But they're easy to install, so most sites have them. Consequently, it's as much the ubiquity of Google ads that signifies "amateur" as the absence of the more branded display ads (e.g. Acura.)

People often comment about what Google ads I have on my site, but I have no control over them, whether it's advertising a camera or ginseng extract is up to them, not me. Frankly, I think Google uses it to punish bloggers. I wrote an only minimally critical piece about Google in 2007, and ever since then they've been serving Dianetics ads and destroying my email with the Android.

But not that I am aware how I (previously unconsciously) made a judgment about websites based on the kind of ads it serves, the scientific question becomes: does the ad change the traffic?

So I looked.

II.

It's only a few hours into the Acura ad campaign, but I can tell you the trend: it hasn't increased the number of hits to the site, but it has changed the click through rate. About 10% more people by this time have clicked through to read posts (in other words, fewer people landed on the homepage and left without clicking on a post.) I am amazed at this result, but there it is. The presence of an ad for Acura enticed people to stay awhile.

Bigger websites out there should take note. If you run a stock advice site, make sure your ads are from the big brokerage houses and banks, simply because it looks like they endorsed you. And if you really want to look like a professional, dump the Etrade ads and get WSJ or Goldman Sachs to advertise with you.

But if it turns out to be true that the type of ad alters reader behavior, then the next question to ask is: what would happen if you placed a fake Acura ad on your site? Copied one from some other site and slapped it up there?

People already do this to themselves: luxury car logos as necklaces (old school, I know); college stickers on the rear windshield. This isn't the same as having the product around to brand you; nor is it the same as the product itself prominently displaying the logo (e.g. Juicy on the butt). This is a conscious decision on a person's part to take the brand (not the product) and use it to endorse themselves.

Could you command a higher subscription rate if your ads were better? Could you get better advertisers because they see an Acura ad is already there? Could you manipulate the market by using fake ads?

I'm not sure this has ever been studied, but the ramifications are huge: for one thing, it would mean the end of display advertising. Why would they pay you, when you maybe should be paying them?

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http://twitter.com/thelastpsych

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For those with ad block-- do me a solid and turn it off when you visit this site. It's better than a subscription...

4 Easy Steps Towards Weight Loss That Aren't Drugs, Diets, Or Excersise

2010-02-01T05:06:27Z

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

]]>
I.

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

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

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

Meal 1: steak and potatoes

Meal 2: bread, peanut butter, and milk

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

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

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

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

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

II. How much insulin do you really need?

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

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

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

(From Aug 2009)

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

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

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

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

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

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

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

III. Small Changes That May Help More Than A Little

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

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

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

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

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

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

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

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

3. Get more sleep.

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

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

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

4. Put cinnamon on your meal.

A bit of a cheat, but...

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

The Massacre Of The Unicorns II

2010-01-26T17:37:19Z

if it had a horn, I'm sure it would be a rhinoceros

]]>
It's almost a trivial point-- we're going to rely on it anyway, why debate it? So the question should better be phrased, "to what extent should the future of psychiatry rely on evidence generated now?"

In a series of articles Nassir Ghaemi tries to justify Evidence Based Medicine in psychiatry; specifically, the primacy of evidence over theories or models.

Ghaemi's says clinical realities are more important than theories, and EBM allows for the study of clinical realities. Any deficiencies in the evidence-- confounding bias, diagnostic uncertainties, etc, are really a problem about the application of the studies, and not about the possibility of EBM in psychiatry. In other words, psychiatry is sound, but we need more and better data.

Ghaemi is arguing for an empiricist's approach, as opposed to a top-down theoretical approach-- one that starts with a theory, with concepts, and either ignores evidence or bends the evidence to conform to an existing theory. (His eg: psychoanalysis.)

II.

He asserts that the foundation is clinical observation, which is then studied further using scientific methods. For example, hormone replacement therapy done on thousands, later determined to be ineffective if not harmful. See? More evidence, better practice.

Hormone replacement therapy was the cure for many female illnesses. Decades of experience with millions of patients, huge observational studies with thousands of subjects, and the almost unanimous consensus of experts all came to naught when randomized studies proved the futility of the belief in that treatment (not to mention its carcinogenic harm).

A moment's reflection shows this argument to be illogical. Hormone replacement therapy did work. It had great risks, but to say that it was a failure is wrong. "It was the cure for many female illnesses, but..." So it was adequately tested in all of them, indicating its futility?

Ghaemi would respond that we would need more studies to determine the efficacy and risks in each indication, in each population. That would be right, but that's not what happened: doctors generalized the failure of a medication based on the outcomes in a restricted symptom set.

"Not better than placebo" is another false start. If a medication and a placebo both show a 25% response rate, it doesn't mean the drug is "no better than placebo": what if two different 25%s responded? Would the group that "responded" to the drug also have responded if crossed over to placebo?

The same is true for symptoms: if placebo and drug both result in a 25% reduction in symptom severity, it neither means the drug is a failure, nor, indeed, that the placebo is a placebo.

"Well, we'd need more and better studies." Of course. I'll wait at the bar.

III. Pay No Attention To The....

This story is apocryphal, so consider it a parable:

Pierre Eymard and friends were studying novel antieplieptics, and used dipropylacetic acid (a solvent) as both an intravenous vehicle for the drug, and as placebo. They observed that the placebo worked, too, preventing seizures at the higher concentrations.

If this had been a phenotype without visible effects, it would have been a perfectly ordinary conclusion that drug was not better than dipropylacetic acid-- aka Depakote.

"But placebos nowadays are inert." Is the fluorescent lighting in the office a placebo-- maybe it makes the anxious depressed patients more anxious? "Come on, those studies are from 1990." I guess that means the question had been satisfactorily resolved, requiring no further investigation?

"Well, more studies are needed..." Tell the bartender I take my rum straight.

IV. Improvement In Depression

Take the simple example of depression, as measured by the popular Hamilton Scale. The scale measures insomnia and weight loss, but not hypersomnia and weight gain.   Using this scale, a patient who sleeps too much and eats too much is less depressed than someone who sleeps too little and has lost weight. And, any drug that fixes sleep and makes you gain weight has an advantage over drugs that don't. In fact, a third to half of the improvement on the Hamilton could be accomplished by improved sleep and appetite alone. Go Zyprexa.

Note that the results of drug trials are reported only as total scores; you have no idea what symptoms the drug is fixing, or not. "But it's not powered to detect those effects." Ok, but it isn't designed to tell you if it's an "antidepressant," either; only if it lowers scores on the Hamilton in this single sample group.

"We need more studies, more scales."   But in the meantime we're left with "X is an effective antidepressant."

The standard academic line is that the evidence indicates all antidepressants are generally equally efficacious. Think about this. Have you ever met a single patient for whom that was true?

For a hundred reasons, none of that data applies to the patient sitting in front of you, yet it is the best information you have to go on. You have nothing else. Ok, go. The problem is not in the application of evidence to your patients, the problem is in the application of the theory that the evidence is creating in you onto your patient.

The Tohen data may show that Zyprexa is efficacious in depression, but when you prescribe it you are thinking, "antipsychotics in general are efficacious in depression in general, and I need a sedating one." You are doomed.

"But more studies are needed..." I look forward to reading them, or passing out, whichever comes first.

V.

That's the issue. In order for this to be a science, there has to be a testable hypothesis. There isn't any of that in psychiatry.

Example: antidepressant induced mania is the kind of testable question amenable to scientific investigation. Do they cause it, or not? But it's not easily answered, indeed, it cannot be answered. Which antidepressant? What's an "antidepressant?" Cymbalta, Pamelor, or Seroquel? Or CBT? What about semen? Which symptom of depression is it treating or not treating that allows you to call it an "antidepressant"?   You could do a billion studies on every drug ever made, in every description of "depression" imaginable and that would only allow you to say, "ah, I know the answer in a billion specific situations" but would still have no insights into the nature of the phenomenon.

Why don't all antidepressants cause it? "Well, there are exceptions to the rule." You've been infected: the rule is meaningless.

When you give someone Paxil, you are playing the odds: this worked in 25% of the guys we gave it to in 1997. There's nothing wrong with doing this, that's what you're supposed to do; but it does not allow you to speculate on either the nature "antidepressants" or "depression."

Simply put, the problem with "Evidenced Based Medicine" isn't the evidence, but the "based." Existing evidence can guide practice, but cannot be used to create a general practice model. "Mood stabilizers are the cornerstone of treatment in bipolar disorder." While I have no idea what you're talking about, I'm certain to be punished if I don't oblige.

In physics, such empty theories don't hurt anyone, and there's value in the theory itself. String theory may turn out to be wrong, but you at least are going to be really good at math. Okay.

But in psychiatry these empty questions and empty answers are still applied to social concepts as if they carried the weight of scientific validity. The question of "antidepressant induced mania" may be empty, but that doesn't stop the legal system from using it. You can't imagine the defense proposing that at the precise moment of the murder, the universe split into two equivalent eigenstates and the defendant, in this eigenstate, had been already determined to have had to have been committing the act of murder, which he already had even before he started; but that explanation carries considerably more scientific merit than the psychiatric one, by which I mean both have absolutely none at all. Wovon man nicht sprechen kann...

VI. Here There Must Be Dragons

"But you're not really arguing against the primacy of empirical evidence, you're arguing about the misapplication of that evidence. You're arguing against incorrect generalizations, against lumping data sets together to invent a clinical model."

No, it's much worse than that.

The problem isn't that the data is sound, but we shouldn't hastily extrapolate or generalize from that evidence. The problem is it is impossible not to do this.

The first reason is because of the use of words. "I met a blonde girl last night." Oh really? he replied knowingly. The words "depression" or "bipolar" or "antidepressant" all existed before we started using them. "Bi" and "anti" and "relapse vs. recurrence" all have connotations that may have no relevance to the way they are used now, yet those connotations will inevitably surface. It seems as though "evidence based medicine" has discovered that the antipsychotic Seroquel is also good for depression, but that's not science, it's an accident of history: 15 years ago the molecule could have been tested for depression, only to now be approved for psychosis. The evidence, the science, may be neutral on the drug's identity, but it will never be equivalent to an SSRI in your mind. In order for it to be successfully rebranded, everyone who learned it the other way has to die.

Second, the explicit purpose of psychiatry is to apply the discoveries immediately. The hasty generalizations and applications aren't a byproduct of the field, they're the whole point. We don't have time to wait for a physiological explanation for bipolar, we have to get people better now. But while extrapolating from "kindling theory" or one antiepileptic's mania data to a theory of "mood stabilization" is a noble attempt, it's still wrong.

Third, our brains have no alternative but to assume causality. No matter how many times you say "X is associated with Y" we will think "X causes Y." Academics like to point this mistake out when residents do it, but everyone is guilty of it, all the time. This isn't a criticism of human laziness, this is how we're designed. Our brains can't help it, they do not allow for a vacuum, they force causality. The brain may not let it become conscious, but you'll act like it, breathe like it. Even when you know it's wrong. I know how a mobile phone works, yet I still yell louder when it starts breaking up. The only way to stop assuming one explanation is to be given another explanation.

Fourth, while 1 + (-1) = 0, a positive study is never completely refuted by a negative one-- and vise versa. Even if studies are of identical design in the exact same patients, the marketing of a study-- who wrote it, where it was published, how many "thought leaders" got behind it, how many pages, tables-- all of this supersedes the content. Even if you successfully appraise a single study on its merits, the rest of the vastness of psychiatric literature is available to you only by rumor. When the fashion turns away from SSRIs and North Face jackets, you'll frown when they occasionally reappear.

Fifth, simply asking the question often overwhelms the evidence. If you ask, "does Geodon cause QTc prolongation?" it immediately stops mattering whether the evidence shows conclusively that it doesn't, or that it was a mistake; it even stops mattering whether you even understand what "QTc prolongation" means. The moment the question is asked, you are forever condemned to pause before prescribing Geodon.

VII.

I've avoided discussions about groupthink or specific biases in studies as they are incidental to the fundamental problem of psychiatry, which is a faith in the primacy of evidence in the absence of any interest in a theory of mind. Evidence can, should, and does inform practice, and none of its shortcomings should change the way we use it today. But faith in evidence hasn't moved psychiatry forward at all in 50 years. More evidence will not fix this, because there's nothing guiding the evidence.

The unfortunate truth is that most of the evidence in "evidenced based medicine" is at best too limited for general application, at worst wrong. Many of you will reflexively recoil from this, retreating from the vertigo to the crowded safety of your peers, journals, and false idols, but this empiricism is only another kind of apostasy. Repent.

I'm Building A Rape Tunnel

2010-01-23T17:40:39Z

i'm trying something new

]]> Artlurker:

...THE RAPE TUNNEL has come under fire from Columbus-based feminist groups not to mention local law enforcement officials. The artist plans to place himself in a room, the only entrance or exit being a 22 ft long plywood tunnel constructed by Whitehurst [the artist] himself. Then he says that for the duration of the gallery's opening he will rape anyone who travels through the tunnel into that room.

Why is he doing it? For effect:

Why rape?
Because as an artistic gesture, it's one of the most impactful I can think of... It dawned on me that if the work [we local artists] created had never existed, the world would be no different than if it had. None of it mattered to anyone outside of our small and insignificant circle of peers. I wanted something that would have more impact.

...I want to make it clear that I plan to make the experience as unpleasant as I possibly can to anyone who dares to crawl through the tunnel. I will try to the best of my ability to make them regret their decision.

...I'll try my very best to sexually assault him or her. The tunnel is constructed in such a way that it gets smaller the closer you get to the project room. The bigger you are, the more difficult it is to comfortably crawl out. And trust me, I have a lot of secrets up my sleeve to ensure that I can overpower anyone that comes through the tunnel.

We can have a discussion on whether this guy is a narcissist, a douchebag, a genius, or an idiot.

We can have a whole discussion on what should be the role of art; whether aesthetics exist independent of our consciousness or only because of its interaction with it; what constitutes art. We can discuss whether Warhol was an innovator by giving the artist the godlike power to decide what things are; since I'm an artist therefore this is art, and it can only be discussed as art-- you would no sooner describe War And Peace as "savory with a hint of paprika--" and in this way, The Rape Tunnel must be judged and described only as art and not as a legal or ethical matter;

or, whether Warhol was a hack who learned the wrong lessons from Marcel "is everyone here a moron?" Duchamp, in which case the Rape Tunnel, its artist, and anyone who goes to see it should be rounded up and sent to the spice mines.

So you can have those discussions: here, here, here, or here. I'm, however, going to discuss something else.

II. One Third Of Respondents Took It Personally

I don't remember where I read this statistic, but it seemed intuitively obvious: 9/10 participants find gang rape pleasurable.

The Rape Tunnel is a hoax; the "art" isn't the tunnel but the story about the (nonexistent) tunnel. The impact is in the (plentiful) discussion about it. Bravo. Score one for trolling.

But if the purpose of the art is the reaction, then the reaction is, in one third of the comments, hate:

Someone should turn this into the Self Defense Tunnel and shoot this asshole in the fucking face
I suspect (hope) someone will go in there with a lead pipe and crack his head open as he makes his move.
Someone please, for the sake of art and humanity, burn this down with him in it.
You have concealed carry there, right? Mr. Whitehurst, meet my friend Mr. Glock. Problem solved.
I'll be sure to pack my gloc-9 before checking out this exhibit.

People who did not have a weapon brought black men:

Probably not real, but if it is we should get someone like Mike Tyson who is tough, mean and has an attitude to go down the tunnel. After Mike beats his ass and bites his ears off, he'll BE art.
I will be there and i'm big and black
EYEM COMIN WII SEA WHO GOES MID evil You clownie Girl (by "Always Were Black")

References to raping him were not unexpected:

It would be quite interesting if someone with HIV decided to take a small trip through the tunnel.
Are there any large, strong, gay men willing to stop by and just pound this guy a new asshole in his little tunnel? Ya know, for the sake of ART? What a douche. Art fag.
if Dick Whitehurst is looking for impact, why not send a large convicted male rapist with a long history of brutally abusing cellmates in there with him. i can't imagine a more appropriate happy ending...
I think that someone with AIDS should stroll down that tunnel and give that loser HIV baby! and then when he's done raping you, say... "I have AIDS, and now you do too! Put that in your pipe and smoke it dirtbag!"
I just hope someone with AIDS goes in with a bloody diseased anus, gets raped and then asks him how he loves his new AIDS

though some creativity was displayed:

he said he'd do anything that comes in-- why don't we send in like random attacking animals like cobras, badgers, porcupines
two words: Chuck Norris

I'm specifically interested in the third or so people who expressed these sentiments. Why so much hostility? First, you don't have to go in. More importantly, why is this level of anger not directed at actual rapists? Years ago I lived near 180 and Broadway in NYC. That's a Rape Tunnel. If you go there there will be a guy waiting to rape you, sometimes they change shifts but there's always someone on duty. And they're hiring. Go there, get raped. EOM.

But no one is taking the A train north to kill that guy. In fact, you've basically accepted his existence, you've ceded that entire neighborhood to him. You don't like him, of course, but you don't hate him, you just put him out of your mind, you put that entire area out of your mind. Meanwhile, this artist, an ordinary man, who is only raping volunteers, who has not actually raped anyone-- that guy needs AIDS.

"But this guy is a douchebag/evil/narcissistic/idiotic--" And the guy on Broadway isn't? He's raping because he doesn't have healthcare?

"But he's trying to pretend rape is art!" So the crime of impersonating art is worse than actual rape?

etc.

All arguments about rape fail. You don't hate him because he's a rapist, you hate him because he isn't a rapist, he doesn't seem to know he isn't a rapist, and is going to rape anyway.

III. I Just Made You Hate 9 Gang Rapists

Cyril Connolly said, "Hate is the consequence of fear; we fear something before we hate it." He's wrong.

There are no special insights available about the nature of anger; but the nature of rage is well described. If you're willing to agree that the above sentiments are rage-- the irrational, out of proportion blinding hate that anyone else observing it thinks is pretty nutty-- then there's plenty to learn from it.

First, the rage comes because this guy is weaker than us. When we feel safe, when we're not afraid (of him), we're free to explode in rage. (That's why there's road rage and not elevator rage.)

In every horror movie I have ever watched, no one, neither characters nor audience, hated the killer. They're too afraid to hate. In fact, sometimes they side with the killer-- think of an audience of teen boys laughing at the funny/horrifying way the victim was butchered. (And, in reverse: only when they start to hate, when they feel the rage, do they become powerful enough to kill the killer.)

Fear assumes limitless possibilities: the thing you fear has infinite power, infinite resources, infinite resolve, unknown identity. Hate comes when you know them. Cyril Connolly did not say, "if it bleeds, we can kill it." But he should have.

IV. All rage is the result of a narcissistic injury.

I have no evidence, but I'll wager that none of the quoted commentors own guns, are black, or have ever raped anyone. I'll speculate but not wager they've never been in a tunnel before, either.

All rage comes from a narcissistic injury. So the question, "why are these guys so angry?" should be reframed: "what is it about the artist/the scenario that is a threat to their identity?" They're emphatically not afraid of being raped because they don't have to go to the Tunnel. They are only responding to the artist's words. That's the threat.

The reason you do not fear this artist and the reason you hate him is because you about him. You know how he talks, thinks, that he's an artist, etc. You may make incorrect judgments based on this information (e.g all artists are wimps) but it is that you created a coherent picture of him that is relevant.

The man on 180/Broadway whom you don't know at all is "a rapist," he has a right to that identity and you're not messing with it.

This artist isn't a rapist, he has no right to self-identify. How is he allowed to give himself so much power? You can't do it, you couldn't grasp that kind of power, you couldn't be "a rapist," because you're not that kind of person.

But he wasn't either.

V. How To Rape Everyone At Once

There's a lesson here.

If you're running, say, a newspaper, and want the population to fear someone, you focus on identity and offer no other details not consistent with that identity; you fix the identity as primary. You don't describe him, you declare him.

To make people hate someone, start from fear but then attack the identity. Offer otherwise irrelevant information that puts them not in a negative light-- too obvious-- but in a contrasting light.

To everyone else not intent on destroying our civilization to sell copies, there's this advice:

When you find yourself hating someone (who did not directly hurt you) with blinding rage, know for certain that it is not the person you hate at all, but rather something about them that threatens your identity. Find that thing. This single piece of advice can turn your life around, I guarantee it.

Most Frustrating Technology of 2010 (so far): Google Android

2010-01-18T18:46:14Z

if I see this thing in my house, I'm stabbing it

]]>
The Motorola Android (Verizon) does not connect with Yahoo! Mail properly. There are two big glitches:

1. Deleted messages reappear the next day, and read messages re-highlight as unread. There's no predictability or periodicity to this. It can happen in an hour, or in two days.

2. When you reply to an email on the Android, it saves thousands of copies in your Yahoo! sent mail box. Last night I deleted 46000 messages.

This is what I've done so far. I've followed the Verizon and internet directions:

Make sure Wi-Fi is turned off
Press the E-Mail icon (the default Android E-Mail application)
Enter your Yahoo E-Mail address and password
Press "Manual Setup" in the lower left hand corner
For "Incoming Server Settings" set the IMAP server to "imap.mail.yahoo.com" and the Port to 143
For "Outgoing Server Settings" set the SMTP Server to "smtp.mobile.mail.yahoo.com" and the Port to 587
Check "Require sign-in" and press Next
Select how often your Droid will check for Email, and choose default options
Give the account a name and set your display name for outgoing messages

With these instructions the phone deals with email properly except for the two glitches noted above.

I have tried variations:

Removed the "mobile" in step 6 (so it is just smtp.mail.yahoo.com). No.
I have turned off the "saved sent messages" in the Yahoo! Mail account options. It still saves.
I have entered the username as both" XXX@yahoo".com and just XXX. No.
I have tried this with the free Yahoo! Mail as well as with the paid Yahoo! Mail Plus. No.
I have tried driving over it. No.
I have tried changing the outgoing settings to plus.smtp.mail.yahoo.com as well as plus.smtp.mobile.mail.yahoo.com

I realize I can just switch to GMail, but if anyone knows how to resolve this, please let me know.

Update:

7. I tried changing the incoming mail server to imap.n.mail.yahoo.com. No.

I determined that the copies are made each time the Android connects to Yahoo to check for emails, e.g. every 15 minutes, every time you send another email, or every time you hit refresh. It makes 2-3 copies each time (can't figure out why) but over the course of a day...

Update 1/24/10

The problem appears to be hardware or carrier, not software. The Motorola Droid runs 2.0 and has the problem, while mytouch runs 1.8 and is free of this abomination.

However, the Nexus One on Tmobile has the problem, too. ~~He said he fixed the problem by removing himself from his Contacts. This did not work for me (I wasn't in the contacts.)~~ (Nope-- this turned out not to work.)

This Man Killed His Family And He Doesn't Know Why

2010-01-17T15:35:35Z

I guess I didn't want any witnesses

]]>
He had the kind of time in Cancun you'd expect: drinking beer, smoking pot, and pretending to be a New York Times reporter (he had always wanted to be one), and having sex with a girl who wanted to be a photojournalist who thought he needed one for his story. Within a month he was caught.

Coincidentally, (or not, depending on your belief in synchronicity;) (or not, depending on whether you believe anything Christian Longo says;) the reporter he was impersonating was simultaneously being outed as having faked an article in the NYT.

Longo was convicted and sentenced to sitting on death row for the rest of his life. But he never confessed. Longo decided he would only tell his story-- the real story, of course-- to Michael Finkel, the reporter he had impersonated.

II.

It's not spoiling much to tell you that Longo is a classic narcissist, but it's worthwhile to go through the examples:

Longo was not a violent or mean person:

In fact, I could not unearth a single violent incident in Longo's life before the murders, apart from a minor scuffle his freshman year of high school. I looked everywhere; I spoke with everyone I could. I didn't even find an occasion when he lost his temper, when he so much as raised his voice. He hardly swore; he never fought with his brother. A woman who attended his church said she used to tell her friends, "I wish my husband could be more like Chris Longo."

But past performance is not indicative of future results because he's never been tested: he's never had a narcissistic injury, wherein you are discovered to be not what you said you were. He thought of himself as-- he wanted people to believe that-- he was a successful, rich, businessman. But the business ran out of money, the debts piled up; so he counterfeited and forged, not to cover expenses but to keep up appearances.

And you can't admit that you've been deceiving your wife for years, that in reality she's married a loser and a liar and a thief... You're trapped.

Trapped? If he cared about money he would have stolen more of it; maybe even killed a couple of people to get their money. No. If he cared about his freedom he could have abandoned his family and fled the country. No. If he felt guilty about what he had done he could have found Jesus or simply killed himself. No. The thing he cared about more than anything else was his identity, and the ones who reflected that identity back to him were his family. They had to go.

Probably, you don't understand how killing people you love so much protects your identity: aren't you now going to be exposed as a murderer? But if you kill your family, then no matter what else happens to you it doesn't matter, because they will never know. You did them a favor: they don't have to live with the pain of knowing you are a fraud.

III.

Even a narcissist is going to feel some remorse when he kills his family, right? It's not like he didn't love them:

When thinking back about times in life where my heart was squeezed in my throat, nothing hurt more than when Sadie fell off the swing that I was pushing her on. To see tears fall from your child's face that you are the direct cause of was more painful than anything that I could remember. It's still painful. How could I be so horrible & still have that sort of pain?

Nope. Those are reflex emotions, the kind you feel watching a romantic comedy or a porn or Beaches.

Also, he noted, as further refutation of his psychopathy, "I got choked up during E.T. & Titanic."

That's right, he said choked.

But his reaction to the photo [of his smiling kids] disturbed him. "I'm not really feeling what everyone else feel's," he wrote, tossing in, as he often does, an extra apostrophe. "What should be most difficult to stomach is what I've done [the murders], yet somehow that part is still palatable."

Narcissists don't feel guilt. Only shame.

IV.

Guilt implies an internal sense of right and wrong. Whether it originates from your religion or your parents or the penal code or Star Wars isn't relevant, only that external rules are then internalized, and you then build an identity around them. So that when you violate them and there is no way anyone noticed, it still gnaws at you because it conflicts with your ego, who you are. Id exists from birth, so superego has to precede ego.

Shame comes not from the action but from the exposure. You wouldn't say you were ashamed unless you have been observed, caught. Shame is a conflict with reality: I think I'm this kind of a person, but now this other guy has external evidence that I'm not.

A narcissist can't feel guilt because, while he admits to external rules (religion, ethics, etc) those rules are always secondary to his identity. As long as the identity is intact, you didn't do anything really wrong. There's no internal conflict with your sense of self because your identity has one superseding rule: self preservation. You will sacrifice anything, including your life, to preserve that identity. That's why your boyfriend killed himself to get (back at) you.

If Christian Longo had been arrested in Cancun for forging checks, he would have felt worse about that than about killing his family. And he will always feel worse about anything that exposes him than about killing his family.

Longo's facade in prison is the same as it was in the outside world: a successful businessman. On death row, people think he's a stock-market whiz. And on the surface he seems to be. He subscribes to The Wall Street Journal and Barron's and often keeps his TV tuned all day to CNBC. He supposedly calls his broker with picks and earns big profits. It's actually an elaborate ruse. "All of that pretend stock market playing is believed to be real," Longo writes. "I've never told anyone that it's not. And I use the phone for sufficient amount's of time to all for that thought to seem legit."

Maintaining the stock-market lie, Longo writes, is getting "exhausting." But he can't be honest, he explains, because of "extreme embarrassment."

This will never stop.

V.

There's a passage in Finkel's article that's meant to be poignant: for the first time, Longo tells in graphic detail how he killed his kids. He describes putting them into their respective car seats and strapping them in, driving to the river, putting a rock in a pillowcase and tying it to one ankle, throwing the kid in the river and then going around to the other side of the van and repeating the process with the other child...

"I can see the kids so clearly in my mind now," he said. "You know when you catch a whiff of somebody's scent and how vividly it brings back so many images? That's how I feel about my kids now, I can feel them, smell them, touch them in my mind. I can hear their voices. See their faces. But I can't remember who I killed first."
A tear escaped from his left eye. Just one. He wiped it away quickly.
"I can't remember who I killed first."

This is an vicious, absolute lie. He killed the child on the driver's side first, and every parent knows which kid is on what side. This is a show, a pretense, designed to invoke sympathy for his suffering (note the single tear) and appear as though it wasn't really him who was doing it-- I'm not really the kind of person who would kill his kids. The problem is that he is exactly the kind of person who would kill his kids in this way for these reasons.

In fact, nearly everything Christian Longo says is bullshit. Words, words, words, bullshit and more words:

At first, Longo had blamed a drug-addled intruder for killing his family. Then he accused MaryJane of initiating the murders. Then he said he wasn't really sure of the details. He testified for four days but never convincingly explained what happened that night...

This isn't a coherent defense, it's pass interference, it's reasonable doubt. It's not important what did happen, it's only important that it wasn't him.

...using charm and guile and a steady stoking of my journalist's natural curiosity (he was innocent, he was framed, he had proof, he would show me), he soon became deeply enmeshed in my own life. In the first year, we exchanged more than a thousand pages of handwritten letters.

And these endless words and the "enmeshing" into your life are a way of wearing you down into giving him the benefit of the doubt. Look, you know me, you know the kind of person I am, right? I can go on and on about this all day; just trust me.

VI.

What I'm about to write isn't to further condemn him but to show you the psychology, the moves, so you can recognize them elsewhere.

Rotting away on death row is not a narcissist's idea of a good ending for his movie. Where's the drama, the self-actualization, the people talking about you? No one cares about you, no one wants to hear your nonsense about who you think you are (hell, he's spending time trying to convince convicts that he's a daytrader).

Longo found a way to make it worthwhile. Narcissists imagine themselves the main character in their own movie, and Christian Longo decided that movie was Seven Pounds.

The movie stars Will Smith, who, after accidentally killing his family in a car wreck, seeks out worthy people who are in need of organ transplants. And then kills himself, with instructions to donate the organs to those people.

I'll let you imagine how Longo envisions this playing out. Of course, it doesn't matter how it ends, only that in the interim

And yes: so happy. He has a mission, a focus, a purpose. In a way, the project has transported him beyond the prison walls. He decided not to drop his appeals after all; rather he's aggressively pursuing them full force, likely putting off his execution date by at least a decade. He needs the time, he says, to work on GAVE [changing the laws so that the executed are allowed to donate their organs.] He wants to live.

Of course he does. This is a trick, you think the movie fits because of the organ donation angle, but the real association isn't with organ donation but with Will Smith, the sleight of hand that it was an accidental killing of his family, yes, he did it but no, it wasn't exactly him, he doesn't even remember it. The organ donation is secondary. He wants that every time you think of Christian Longo you think of a man who ultimately performs a selfless act to make up for a tragic mistake.

Will Smith's character felt guilt despite no one else blaming him for the deaths. Longo is the opposite: everyone blames him, except himself.

VII.

The Esquire article is full of these examples and is worth reading. But I can hear you: ok, he's a narcissist, I get it, but if there were no warning signs, how would anyone know?

I don't have an answer. I can say confidently that Zyprexa and Seroquel aren't going to help.

But there's this: Longo killed before he was exposed. LA Fitness shooter Sodini killed because he felt the game was soon to be up. Etc. It seems that the truly dangerous time is right before, when the terror of the possibility of exposure grips them, and so all options are on the table. After exposure there is only defense and running and crying and anger, and rage and violence, too, but not the kill-anyone-who-knows kind you see the week before the pictures are to be released or the month before the girl goes off to spring break.

I can't tell you what to do about the guy you suspect is going down the wrong road, but I can tell the guy himself what to do: turn back. You know it's complicated and exhausting to keep up the appearances, to keep pretending, even if it's working, because eventually you will get fat, eventually you will get the bill, eventually she will leave you, eventually you will fail. It is inevitable.

VIII.

You want a simple answer: why did he do this?

At no point in the Christian Longo timeline from birth to now was murder even a remote possibility. We look for reasons he did this: were there signs, a homicidal triad, bipolar, drugs, genetic history? We want reasons why it happened. There aren't any.

----

More on Longo in the NYT.

The important question is the one no one asks anymore: what was holding him back?

Everyone Goes Crazy In A Different Way, As Long As That Way Is The Same

2010-01-14T15:31:50Z

"yeah, everyone in America is so fake"

]]> The NYT writes The Americanization of Mental Illness:

In some circles, it is easy to make friends with a rousing rant about the McDonald's near Tiananmen Square, the Nike factory in Malaysia or the latest blowback from our political or military interventions abroad. For all our self-recrimination, however, we may have yet to face one of the most remarkable effects of American-led globalization. We have for many years been busily engaged in a grand project of Americanizing the world's understanding of mental health and illness.

The article cites the experiences of a Chinese psychiatrist in the 1990s who tried to explain the culture specific ramifications and meaning of anorexia in Chinese patient: not a fear of being fat, but a vague feeling of GI distress. This was some unconscious manifestation, a somatoform disorder.

Then a woman passed out and died from anorexia on a subway:

In trying to explain what happened to Charlene, local reporters often simply copied out of American diagnostic manuals. The mental-health experts quoted in the Hong Kong papers and magazines confidently reported that anorexia in Hong Kong was the same disorder that appeared in the United States and Europe.

What happened next seemed to surprise the psychiatrist: not only did anorexia rates start to rise, but no longer was it due to the vague GI distress. These new anorexics specifically cited "fat phobia" as the core.

Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they also may have changed the expression of the illness itself.

Dr. Lee surmised that because the language to describe anorexia came from America, then

When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.

There are two points to ponder: first, what are we to do with the genetic basis if the incidence of a disorder jumps so suddenly?

Second, and more importantly: if Chinese people are being nudged into developing western style diseases because they are being bombarded with western psychiatric descriptions, then what do you think happens to western people?

That feeling you have is what Sartre called nausea. Seroquel won't help.

II.

The article, through Dr. Lee, blames the usual suspects:

Mental-health professionals in the West create official categories of mental diseases and promote them in a diagnostic manual that has become the worldwide standard. American researchers and institutions run most of the premier scholarly journals and host top conferences. Western drug companies dole out large sums for research and spend billions marketing medications for mental illnesses... Taken together this is a juggernaut that Lee sees little chance of stopping.

In this case the problem isn't psychiatry, it is the popularization of psychiatry: it is the press, it is the media. She didn't read the DSM, she read the newspaper (and magazines and TV and...) They're not simply popularizing western psychiatry, either-- they're popularizing western culture. It's a safe bet that "local reporters" are going to be more westernized than "locals." But reporters have a forum, so they get to determine the narrative. The "local reporters" in China basically did what the American press does: "here's what we think happened. Hit Print. There, now it's true."

When Google threatens to pull out of China, it isn't because of human rights violations. It's a battle for who will describe the universe. NB: Google will win.

III.

The article describes an experiment that could be called, "You rise to the level of your diminished expectations."

A subject tried to silently train a second person to press some buttons in a specific order. He is told that the second person had a psychiatric disorder either due to "life events" or to a "brain disease." The only feedback they could give was to administer a very mild shock, or a very big shock, when the second person got the pattern wrong.

When the subject was told that the second person had a psychiatric disorder due to life events, they got the mild shock. When it was due to a brain disease, they got the big shocks. If there is already something wrong with their brain, the subject figured he had to make things obvious.

The point of this example was to illustrate that other cultures may end up stigmatizing the mentally ill if they begin to incorporate the Western idea that these are strictly brain diseases. Too late: incorporating the western idea was what gave them the disease in the first place. Seroquel won't help that either.

IV.

"You have a background in genetics. How can you flippantly say that ideas are causing psychopathology?"

The interaction of genes of risk with other genes that we have not yet identified-- say, an insulin receptor or the size of your pancreas or your ability to fight a flu infection-- that we wouldn't even think is relevant, may be quite relevant. Most of our psychiatric genes of risk are risks only in certain environments. That may seem obvious, but consider that a person with schizophrenia, in which the mind has difficulty with reality, may be even more ill when their reality is actually less real: a Chinese teen in China saturated with western images. Perhaps if he never turned on the TV, he never would have developed the symptoms (or they would have been less.) The Japanese hikikomori phenomenon may be an example.

Go back to the story of the Chinese anorexic woman who died. The article doesn't point put the obvious: she had already been infected by the west. Her name was Charlene.

Certainly I don't hate the west; but when you dip your feet into someone else's culture without the accompanying mental and social infrastructure that goes with it, well, you're going to get anorexia. Or something.

Is Genetically Modified Food Safe?

2010-01-11T17:04:02Z

uh oh

]]> study on the safety of genetically modified food is important for two reasons:

1. This is the first of its kind (!)
2. This is the longest in vivo study (in animals) on the safety of this food: 90 days. (!!!)

Rats were given one of three strains of genetically modified corn, or a non-GM corn feed, and studied for 90 days.

The results were not encouraging,

Our analysis clearly reveals for the 3 GMOs new side effects linked with GM maize consumption, which were sex- and often dose-dependent. Effects were mostly associated with the kidney and liver, the dietary detoxifying organs, although different between the 3 GMOs.

For example:

While these are not gigantic results, keep in mind that these are rats are eating at most a 33% mixture of GM corn, and it's only for 90 days. If you want to know if they cause cancer, just check with your kids in a few decades.

II.

It's not obvious to me how eating something with modified DNA is harmful. When you eat DNA, you don't incorporate bits of it into yours, any more than when you eat a pie you incorporate bits of pie.

One corn (NK 603) was modified to be able to withstand the plant killer Roundup, and two others (MON 810 and 863) were modified to produce an insecticide. When you eat this corn, therefore, you are also eating some herbicide or pesticide. In other words, it may not be the GM corn itself that is toxic. If the corn is grown on a farm that is sprayed with Roundup, then you're eating Roundup. It's quite possible this study is measuring the toxicity of Roundup, not GM corn.

Put another way: maybe they should find better ways of washing the corn?

III.

Does washing corn-- or anything-- help remove pesticides?

A.

In one study, water alone was tested vs. Fit Fruit And Vegetable Washing Kit.

Three points:

1. Study 1 fruit had been treated only with captan; Study 2 fruit was treated with a mixture of captan and methomyl.

2. Water and Fit both wash off captan well, but water isn't as good for methomyl, probably because fruits are coated with wax after they have been treated with pesticides, locking in the deliciousness. Water doesn't penetrate wax, but ethanol (in Fit) does-- as does rubbing the fruit. Moral: scrub wash, then peel, then wash your fruit. Soaking them in rum is helpful and delicious but not recommended.

3. This is what they mean by washing: soaking the fruit in 2L of water for 30 seconds, then rinsing it four times, 30 seconds each. Then rinsing again for 5 seconds with 2L fresh more water.

B.

An older study found that water was as good as Fit and even washing in 1% (!) Palmolive, significantly reducing 9/12 pesticides studied. (It had no effect on 3 others, so there's that.)

C.

What about meat?

While many pesticides have been banned (e.g. DDT) they are still in the soil and get incorporated into the plant. In a similar manner, current pesticides are theoretically incorporated into the fat of the farm animals that eat the sprayed plants and feed.

A study done in India found various meats (cow, goat, chicken) to be contaminated with several pesticides, including DDT. None of the animals appeared sick prior to their slaughter. However, and this is the point:

Cooking means steam (in a pot.)

I'd guess that cooking vegetables probably has the same effect.

---
http://twitter.com/thelastpsych

(Part 2) The Limits of Control: The Dream

2010-01-10T00:15:48Z

...wait a second, these aren't matches, they're MacGuffins...

]]> Part 1 here.

Once in a while we gather at a friend's house to watch a movie. We usually go to her house because it is the most inviting and comfortable, comforting; unlike mine, which is really only good for hiding POWs.. Her place, like her, is highly developed but but uncomplicated. Considerable taste but no knick knacks. No decorative soaps. When she's not working (sports reporter) she doesn't wear make up. She doesn't need to. She doesn't need clothes, either, but ignores this advice. Her (ex) boyfriend, whom I assume had a brain parasite, took 6 months terminally asphyxiate their relationship with a combination of weed, surfing, bartending and auditions.

This time I picked a movie I had read about: I picked The Limits Of Control. She wasn't in the mood for a movie, but I had thought she needed a diversion. (Remember, I thought this was going to be an artsy G.I. Joe.)

Of course I was wrong. At about the first cafe scene I briefly fell asleep, then when I awoke a few minutes later I said, "what'd I miss?" and she said, "I filled your cup with strychnine."

Not only did she hate the movie, she couldn't stop telling us how much she hated it. For days afterward. "I am actually angry at the director for robbing me of part of my soul with that stupid, pointless, go nowhere movie. Boring! It was like having to listen to someone tell you their dream."

And then she added, with restrained fury: "This is Chuck's kind of movie."

II.

Freud was clear on two things: dreams are wish fulfillments, and they can only be interpreted using free association. There is no dream dictionary where flying means sex and cougars mean cougars.

Many elements of director Jim Jarmusch's movie are dream like: they draw from waking life, have their meaning stripped away and are then endowed with some other significance, specific to the dreamer.

For example, the title is derived from an essay with the same title by William Burroughs. But don't bother reading it because (quoting Jarmusch):

I don't know why. I love the title. The film does not, obviously, relate specifically to the essay--and I love that.

The two espressos, the shiny suits, "A Point Blank production"-- all are references to real events (or movies or books, etc) which you are tempted to link back to. Resist.   These aren't allusions to something; they are symbols for something else. It's not an episode of Lost. You can't understand their meaning by looking up the references.

The important thing is to say whatever comes to mind.

III.

Whenever a new "contact" approached the Lone Man, they would say, "you don't speak Spanish?" as a secret passphrase.   She thought this was stupid. "He's an African man in Spain, and he doesn't actually speak Spanish-- wouldn't you come up with a better code? It's like using "do you want fries with that?" at a McDonalds."

In the Freudian logic of dreams, an inability to do something-- being lost, stuck in traffic, something is missing-- represents contradiction. And when that inability is accompanied by a feeling of inability-- you're stuck to the floor, it's too heavy, you can't run-- it represents conflict of the will. So you just met a man and you're not sure about him, and you dream you're being chased by a powerful monster, but your feet are stuck to the ground and you can't run. It would mean you're conflicted about the monster (relationship.) But... but the dream as wish-fulfillment means you don't want to escape.

She lit up. "He's passive aggressive. He chose to go to Spain, but he doesn't know Spanish, so he has a convenient excuse not to have to listen to them. That's a classic Chuck maneuver.   There's always a reason why he can't be with you or give you his attention, but he yet he's totally dependent on others to tell him his next move or what to do next, he can't make major decisions on his own. So he waits for you to tell him, and then he picks and chooses what he hears."

"Was the 'two espressos' another kind of passphrase?" I ask.

"No, I feel like that was just posturing, trying to make himself seem unique. It's funny that he gets really mad at the waiter for not bringing him the right order, but he won't sleep with the naked woman."

"How are those related?"

"So, what, he has enough self control to resist sex, but not enough self control to be polite to the waiter?   He's a coward. What guy would not fuck a girl they found naked in their bed?   What is he, 15? Is he a virgin? She's not asking to get married, she just wants sex, just fuck her and get on with it. But he's so nervous around women he has to pretend he's a zen master? Maybe if he fucked her, he wouldn't care so much about how he got his espressos."

No one else would have made this interpretation. I'm almost certain Jarmusch didn't intend it either. But this was, after all, her dream.

"Wow, that is so much like Chuck, always playing the part of "I'll handle everything" but when it comes down to it... That's why he balled out the waiter. He can control himself, but it makes him crazy that he can't control other people or the world around him. So he creates all these rituals he has to do over and over to give himself the illusion of control."

I suggested Freud's interpretation, that repetition with variations (for example, the nude woman, then in a raincoat, then as a painting; the white castle, then a picture, then a statuette) represents a working through of some issue or idea; and that multiple symbols can be seen as working through the same issue in different ways. It clicked.

"That's what all Chuck's games are about, he wants everything exactly right, precise and perfect but that's so nothing ever changes, he never moves forward, he never evolves. Everything has to be by his schedule. Do you know he once said "not while I'm working" to me one time? He's a bartender, for Christ's sake."

So I asked, "why would Chuck want to kill Bill Murray?" Bill Murray plays a Dick Cheney character.   The Lone Man infiltrates his secret impenetrable bunker (not shown in the movie; "I used my imagination") and kills him.

"Bill Murray is his father, obviously. He's spent all this time working through his ambivalence about me and his job and everything else, he's finally mustered the courage to become his own man. Well, he wishes he did. He finally gets power over and he ultimately disposes of people that control him. I think a real father would want his son to stand up to him, because it means he's finally a man. That's why Bill Murray the father figure knows he's going to be killed but isn't scared, he doesn't fight or run.   And he says "you don't know how the world works" with no fear at all, just contempt. Which is actually the kind of thing his dad would say. I could see that Chuck wishes he could get out from under his father and grow up."

"And fuck you?"

"Too late for that," she said.

IV.

I'll repeat that I still thought the movie was boring. But now I'm not sure that matters. I think I am better for having seen it, my friend probably feels the same way. It has stayed with me and altered the way I look at other things.   In the final analysis, what Jarmusch intended is probably irrelevant: the important thing is to say whatever comes to mind.

---

http://twitter.com/thelastpsych

The Limits Of Control: The Movie

2010-01-07T18:08:05Z

Hmm. Matches. Wow.

]]> he Limits of Control in different ways, but inevitably using the phrase "worse than getting raped in the penis." That's typed correctly. I did manage to find three reviews that did not include that phrase:

"It's an art movie with almost no dialogue, action, or story, about characters with no names who are doing either nothing or something that you never get to understand. And it's long."

"Take an action movie, remove all of the action scenes and dialogue, and send straight to video."

"Biggest waste of time I have experienced since the Obama state of the union address."

Here's the IMDb synopsis:

The Limits of Control is the story of a mysterious loner, a stranger, whose activities remain meticulously outside the law. He is in the process of completing a job, yet he trusts no one, and his objectives are not initially divulged. His journey, paradoxically both intently focused and dreamlike, takes him not only across Spain but also through his own consciousness.

Don't ask me why, but this made me excited to think it would be a David Mamet redo of GI Joe: The Rise of Cobra. I was very mistaken. And I got retinoblastoma.

The main character is an iceman, highly focused on the job he was hired to do (which we don't understand.) He almost never displays emotion; he rarely talks. His face is made of concrete. Weird characters talk to him in cryptic sentences, pass him ciphers hidden in matchboxes which he reads, then eats. When he finds a naked billion (on a scale from one to ten, she's a billion) on his bed asking to have sex with him, he says, "never when I'm working." Control. He is frequently shown doing tai-chi, or staring at specific paintings in a museum: for focus. He always wears a suit when he is "working," day, night,sleeping, city, or in a desert.

That may sound like an excellent setup for a movie, except that there isn't any movie to go with it. None. Nothing happens in this movie, ever.

Here's a pivotal scene from the movie:

Now, it may be difficult to see from this photo what is actually happening, so I'll tell you: nothing. At all. I don't mean "nothing" as in "something, but it's boring," I mean nothing. For the whole scene. Let me emphasize again that this is a pivotal scene.

Here's a pivotal video clip:

You may raise an eyebrow: "hey, what are you trying to pull here, that's not a video clip, it's a still photo." Exactly. The Limits of Control isn't a movie, it's a series of photographs, each displayed for, oh, I don't know, 25 minutes each? and set to music. Bring blotter acid.

The movie seems to be offering you clues and hints about what's happening. I paused the movie on one of the ciphers to see if I could crack it, but I couldn't. I googled some of the phrases and images-- nothing. I wanted to figure it out, but couldn't.

The entire movie is populated with surreal images which beg for explanation, or at least a link to the haiku that passes for a script. No.

I have no idea what that building is, why he's looking at it, why he has a picture of it, and why it appears later on as a small statuette.

But, look, I don't own a North Face jacket, it's possible I'm just not hip enough to understand the symbolism. That turns out to be wishful thinking.

Example: Destro asks the waiter to bring him "two espressos-- in two separate cups." Hmm, intriguing. He's very emphatic about it, says it twice. But the waiter, who has to be deaf or retarded, instead brings him a double espresso. Destro yells at him, sends him back-- it's one of the only instances of emotion in the whole film. Hell, it's the only instance of action in the entire movie.

He does this, the ordering of two espressos, several times in the movie. This is framed and shot in such a way as to make its importance indisputable. So you say, ok, what gives? What is the relevance of two separate espressos? Is it a code, a signal? Is it an allusion to an Antonioni film, to Heidegger, what?

Turns out you are wasting your time: this isn't a symbol or clue, it was something that the actor actually did in real life, that the director, who was with him at the time, found funny. So he put it in the movie. "I found it amusing that he blew up at the guy." That's it. 'Art imitates life.'

Another example: the ending does have a sort of climax, but it's not obvious, so if you made it this far in the film you are paying close attention to everything, looking for some sort of explanation like it's the season finale of Lost. Why is does he change into that shirt? Why is he in an airport? Why is it green? etc.

In the last scene, the movie picture appears to jolt suddenly; the only way I can describe it is that it's as if the camera operator started putting the camera down before he turning it off. What's the significance of that jolt? It's in such contrast to the stillness of the rest of the movie. Does it mean it's all a dream? He's killed? What? No, believe it or not, that jolt happens because the camera operator actually did put the camera down before he turned it off. And the director liked the effect.

I had to watch 27 Dresses with Katherine Heigl to detox from this atrocity, but then I ended up getting the bends. But that was the end of my involvement with this movie.

Well, it was until this happened.

Healthcare Reform Is About Protecting Monopolies

2010-01-04T18:50:57Z

Andrew Lawrence predicted it would be completed at exactly the right time, whenever that was

]]>
A Medicare patient comes to a Los Angeles psychiatric clinic for a new psych eval. 45 minutes later, the doctor codes and bills it as "90801 Psychiatric Diagnostic Interview" for $169, fee set by the government.

A month later, the patient returns for a 15 minute med check; the doc codes it as 90862 and bills for $61.

Question: if this appears to be a consistent reimbursement rate of about $4/minute, why are there two codes? Why not just bill Medicare by the minute?

II.

Most people assume the codes are simply government bureaucracy, like penal codes or social security numbers, the numbers are for public use. They aren't. They are a product, they are intellectual property. To use them, you have to license them. They are no different than a Jay-Z song: you have to pay Jay-Z for the right to use it.

The trick is that doctors have no choice, Medicare requires them to use these codes-- that they must first license or buy.

Who owns them? You probably think it's the government, but it isn't: it's the American Medical Association.

In 2001 they made about $70M from those fees. Trent Lott attempted (read: pretended) to try to break this monopoly, but 6 months later the Towers came down and no one needed to (pretend to) do anything after that.

At that time (and now) politicians assumed that the AMA wanted the copyright protection to help doctors, because it prevented the consumer from comparing prices:

The AMA has been able to impose on the entire nation the AMA's obviously self-interested policy against consumers comparison shopping for medical care based on price by suing Web sites and others to prohibit them from posting comparisons of doctor and other medical fees on the Internet using the CPT code [said Trent Lott]

And that sounds sufficiently populist to get support. But it's about doctors. It's about the business enterprise that is the AMA. It makes $70M from the CPT fees, but it makes only half of that from membership dues. In fact, most doctors don't even belong to the AMA (I don't, nor to the APA); it's only about 15% of doctors.

The AMA is in the healthcare business, but the business of healthcare is business.

III.

Lott was completely wrong, he was seeing the AMA as a proxy and protector of the greedy doctors it serves. Wrong. The AMA isn't going to protect reimbursement rates from Congress, but you can be sure it will protect CPT codes. $70M might not seem like a lot, especially in comparison to the money at stake in healthcare reform; but $70M is a lot to the AMA.

At some point in the growth of any organization, it spends increasing resources on its own existence. It's not because it is evil or selfish, it is by necessity. Consider the hypothetical example that the AMA wants to serve doctors, but membership is declining, so to boost revenue in order to serve doctors it tightens its grip on CPT codes, journal fees, etc. However, doing these things puts it further at odds with doctors that they want to serve, resulting in further declining membership, which, by necessity, results in even tighter grips, etc.

This is not an ethical judgment, it's public choice theory, it's survival. So far no problem. This is the important part:

At some later point in the growth of an organization, as the members become more vocal in their disapproval, it begins to question the sanity of its own members; it doubts whether the people it serves even know what's good for them. It assumes that the self-interest of the individual members is morally inferior to the self-interest of the organization.

This point is an inflection point; it is the beginning of the end for one of them.

---
http://twitter.com/thelastpsych

How To Create: Motivation for 2010

2009-12-31T15:24:08Z

he didn't finish it either

]]>

1. The fantasy workspace.

All artists-- and probably all people-- have in their minds the fantasy workspace. "If I could only work in..." Forget it. This is always going to fail. Always, every single time. They are distractions, they sap emotional and creative energy. You may be surprised to learn/assumed that this blog is written mostly in airports, hotel lobbies (wifi), and on my Blackberry.

Here are some famous authors' spaces. At first glance you might say, cool! but look closely, these are basically cluttered (or bare) offices and areas. They're created out of ordinary necessity. They weren't set up, they evolved over time.

You may try to wave this photo at me:

"Look, he's writing in his fantasy studio." Really? 20 books, with a fountain pen and oil lamps? I investigated:

Real life at home follows a fairly consistent pattern. I get up between three and four in the morning and brew a pot of tea. In the cool months, I make a fire in the fireplace and sit down there to write. When it's warmer, I go out on the back porch. We live on the edge of a few hundred acres of pine forest, and it's pleasant to have the trees and birds and animals out there in the dark while I work.
I do my first drafts in longhand, writing with a fountain pen into blank books. I like the freedom from machinery, and I seem to write more and faster that way than with a computer. It also gives me a definite first draft. Like most people, when I compose on a computer I keep jumping back and forth; by the time I print out a "first" draft, it's actually been worked over a bit... There's no electricity on the porch, so I write between two oil lamps -- making up stories about the distant future, using medieval tools.

Much of this set up is necessity, but in any case he doesn't do it for very long:

After I've finished about 500 words, I quit, and retire to the actual study, which is a book-crammed labyrinth of computer and office equipment.

He has a real study, but writes elsewhere to get the juices flowing. Worth noting that he started writing this way only after he had already published several books.

This is what you are thinking:

"If only I had those kind of materials."
"If only I had better canvas."
"If I only had the Glengarry leads."
"If only I was rich."

Then you'd fail. Creative success is taking what's available and rising above that. The "that" doesn't matter, you'll only be credited with success if you go beyond it. Maybe Picasso had good canvas but he had to transcend an entire way of painting, that's what made him great, not the physical painting itself. Otherwise we wouldn't be buying prints.

Stephen King, On Writing:

For years I dreamed of having the sort of massive oak slab that would dominate a room.... In 1981 I got the one I wanted and placed it in the middle of a spacious, skylighted study... For six years I sat behind that desk either drunk or wrecked out of my mind.... A year or two after I sobered up, I got rid of that monstrosity... got another desk -- it's handmade, beautiful, and half the size of the T. rex desk. I put it at the far west end of the office, in a corner....I'm sitting under it now, a fifty-three-year-old man with bad eyes, a gimp leg, and no hangover....It starts with this: put your desk in the corner, and every time you sit down there to write, remind yourself why it isn't in the middle of the room. Life isn't a support-system for art. It's the other way around.

2. Not starting.

A common piece of advice is "just start!"/don't procrastinate, etc.

Let me explain, however, why this is a cognitive necessity.

No matter how carefully you plan something in your mind-- work through details, procure materials, etc-- it can't take into account everything that happens. Try imagining having sex with Paz de la Huerta; and then try actually having sex with her. The first is masturbation, the second is very tricky, although rewarding, business.

Every creative idea is a dialogue between you and yourself (masturbation); every creative act is a dialogue between you and reality (sex.) You can't account for that other half of the dialogue until you begin it.

Reality takes many forms: the light of a computer screen, the need for the "great phrase" to be surrounded by words that are less inspired; hunger, the need to pee, fatigue, caffeine headaches, hangovers; relentless, crippling, blackening self-doubt. You can never account for these except through action. I don't mean they are necessarily obstacles-- they don't necessarily hold you back-- but the are real success of any creative act is that it transcended reality not by bypassing it, but by going through it.

Or you can just go back to masturbating.

3. "I need peace and quiet!" Not exactly.

In airports and wifi hotspots, I am constantly distracted, usually by women, occasionally by lunatics. However, I get a lot done there because both women and lunatics are scared of me and so I am rarely interrupted. Peace and quiet is valuable, but if every 30 minutes the quiet is interrupted by a phone call or your spouse asks you if you bought the ham, you'll get nothing done. Parents tell teens to turn off the FM radio so they can study better, but that act of telling them is far more distracting than two hours of commercial free Hot97. Sometimes, you interrupt yourself (check email).

This is likely the biggest obstacle to practical creation. Creativity takes inspiration from everywhere, but working on the creation requires concentration, mental focus. Interruptions block this. Imagine again, you are having sex with Paz de la Huerta, and your spouse interrupts you to ask if you bought the ham. Seriously, how are you supposed to work like this?

4. 90/10

You can do 90% of something, but the last 10% takes years, or never gets done. How's that novel coming? Almost done, I'll bet.

It's the same process operational in dating. Long term relationships that never quite make the obvious and natural step of marriage; or furtive glances in a bar that never culminate in an audition: "hey baby, before you got here I thought I didn't really want a blowjob. How 'bout some Jaeger?!"

All of those are the same thing: defenses. Abstractly, they are fears of finality. Not finishing means anything can still happen, your identity remains intact: "I'm a writer."

More concretely, they are a form of self doubt not about the success of executing the act which is in your control-- the writing of the book, the asking the girl out-- but of being able to manage the consequences which are not-- the publishing of the novel, sustaining a relationship/finding a burn unit.

5. Deciding to finish.

It's evident I am not a writer; but each post takes me hours to write, over days. I revise constantly, and still the result is-- well, this. However, at some point I have to overcome my strong wish to revise again (and again and again) and hit submit. First, even though every revision takes the same amount of time, the improvement from subsequent revisions quickly plateaus. Second, unless I hit submit, none of the revisions do anyone any good at all.

I have to decide that it's finished. Read again: it isn't actually finished, I have to decide it's finished. Creative acts require a decision to terminate (e.g. sex with Paz) otherwise it can go on forever.

Some creations, like a novel, are large enough that you don't notice you're avoiding termination. So break a big job into smaller pieces each with definite ends that exist reality.

Example: don't write the novel, blog the chapters. It worked for Dickens. The moment the first chapter goes out your relationship to the book will change. Not just due to feedback, but you'll also find out how much of the novel you really had in you; if it's really a novel or just an idea; if the novel is really a derivative of someone else's. Etc.

If you're scared of the feedback, turn off the comments. The important thing is to do something in reality, not in theory. You can procrastinate a single termination point, but it is very hard to avoid multiple, regular, termination points.

Even for losing weight: "I'm going to lose 10lbs by Valentine's Day"-- it's easy to cheat on your goals and say, "well, I'll just make it up next week." Try, instead, taking a photo of yourself in a bathing suit each week and putting it on the fridge. Or mailing it to me. Or putting it on a blog. Force the idea-- your goal of weight loss- to confront reality regularly, repeatedly, instead of once (at the end). You might say this is going to fail, but if this is going to fail, then you weren't going to succeed anyway.

Happy New Year. You're running out of time.

---

http://twitter.com/thelastpsych

"She Said She Had Breast Cancer-- But She Lied"

2009-12-28T19:52:04Z

if it's in here, it must be about breasts

]]> old story because wrong is forever.

Suzy Bass, a math teacher at a private high school, had breast cancer:

Because Bass had recently moved to Knoxville and was single, two Webb staffers--Julieanne Pope, 43, and Terri Ward, 51--became her part-time caregivers. "I left my cell phone on my nightstand every night in case she needed anything," says Ward, the dean of faculty.... When Bass was too sick to teach, they'd cover her classes. And they kept a steady stream of casseroles and smoothies going to her condo. "We'd visit and she'd be shaking, pale and so sick," says Pope, Webb's technology coordinator. At school Bass would cover her head--bald from chemotherapy--with a knit cap, and limp from the tumor in her foot.

Except she didn't: she made it all up.

Listening to Bass detail the outrageous lengths she went to over the years to fake her symptoms is chilling.... Bass learned to draw convincing-looking radiation dots on her neck with a permanent marker... She would also roll up a bath towel, stretch it between her hands and rub it back and forth against her neck as fast as she could to give herself "radiation burns." She shaved her own head with a razor and made herself throw up from chemotherapy "nausea" in school bathrooms.

She did it for years, at multiple schools, with everyone, including her parents.

Why? Not for the money-- she didn't ask for any disability pay/leave. So?

II.

I wish this was a joke: the article first suggests it's bipolar disorder.

Despite all that effort and time Bass spent learning how to appear sick, she claims that every time she feigned having cancer, she truly believed she was ill. "In my mind, I didn't lie to anybody," she says.

Could someone honestly believe she is dying while actively lying about it? That's part of the puzzle Bass's counseling team is attempting to piece together. "It is certainly possible that given her diagnosis of bipolar disorder, Suzy could have truly believed she had cancer," says Marvin Kalachman [who is treating her.]

Note the construction of his explanation: the "known" quantity is "she has bipolar" and because of that, it is assumed she could believe her lies. But in reality, we don't know she has bipolar and we certainly don't know that she actually believes her lies. We only know that she lied. But he's accepted her story and given her an alibi.

This is the real danger of the overdiagnosis of mental illness: it prevents any further analysis of the symptoms. The debate from this point on will be about whether she has bipolar, not whether her symptoms-- in this case believing her lies-- are real.

I don't have to wait long for an example, here's the next paragraph:

"It's possible for a bipolar patient to experience delusions lasting days or weeks during an episode, Dr. McInnis [professor of psychiatry at the University of Michigan and a leading expert on bipolar disorder] explains. In Bass's case, however, she went to great lengths to fake symptoms--not a hallmark of bipolar delusions, he notes.

He is correcting the diagnosis: bipolar delusions don't look like this. "Delusions," as in "she believes them."

III.

Fortunately, the article abandons bipolar as an explanation (though not as her diagnosis), and instead turns to something that is even more wrong:

Marc Feldman, M.D., a world-renowned psychiatrist, has treated more than 100 women who have faked serious illness... he believes he has her diagnosis: Munchausen syndrome, a psychological disorder in which someone feigns or self-induces illness to get attention and sympathy...these people know that they are lying, but typically don't know why they're compelled to do so.

You'll be tempted to disagree with me: "this sounds exactly like what she has."

And, he says, a diagnosis of bipolar disorder does not rule out Munchausen syndrome. Currently Bass's counselors have not diagnosed her with Munchausen syndrome and say they are primarily focused on treating her bipolar disorder

The problem with the article's and the doctors' assessments is that they are being fooled by the content of her lies and not the form. Because the focus of the article is cancer, because she's faking a medical illness, the explanation must be some other medical (psychiatric) illness.

What everyone does agree on is that this is a woman who will need help for a long, long time.

"I feel sorry that she's sick, but I don't want her to do it to anyone else."

"I just wish we'd found the right doctor for her 15 years ago."

Bass is currently unemployed, a medical recommendation. "... I'm sick and I'm working on it every day," she says.

If she had lied for monetary gain, no one would assume it's a psychiatric condition, but because the gain is non-financial, she must be ill. That's because in America, only crazy people do things for no money.

IV.

The content of her lies suggests Munchausen's; if this was accurate, you'd worry about this:

But if Bass herself can't promise that one of these days she won't suddenly start faking breast cancer, melanoma or some other disease, how do I know she won't? How does anyone?

Because she "fakes medical illness for sympathy" the reflex is to focus on the words "medical illness," but where you should focus is on "for sympathy." Munchausen's doesn't predict what was in retrospect obvious to her students-- she lied about everything.

List of things said by Suzy Bass most of us believed...

Had Breast Cancer...Lie
Worked for NASA...Lie
Played basketball for Florida State...Lie
Got hit by a tornado...twice....Lie
Good friends with Archie Manning...Lie
Had dinner with Vince Young, Mike Vick, and T.O....Lie
Wrote 3 textbooks....Lie
Name is Suzy Bass...Possibly a lie

Oddly, the Glamour article misses a lie that was right in front of them:

In the fall of 2005, the school nominated Bass for the prestigious Disney Teacher of the Year Award. "[Bass] may be the finest teacher/inspiration I have ever been associated with in 32 years of education," Jim Gottwald, the Paulding County principal told the Athens State University newsletter.

The actual quote is "Dr. Bass."

Meanwhile, it lists some lies Bass herself revealed, but doesn't recognize their importance:

She once pretended she had a fiancé who died on 9/11, that she'd played basketball at Florida State University and that she'd starred in the North American tour of Mamma Mia! "What I did was wrong, and I'm willing to stand up and admit that," Bass says, "but it doesn't change that my intent was never to hurt anyone. Never. I'm not that kind of person."

The point here is that the faking of cancer is completely incidental to her life's narrative, what is important is the faking. She faked cancer because, simply, it worked very well. If she could have gotten sympathy and esteem and identity from faking being a basketball pro, then the article would be called "She Said She Played For The Celtics-- But She Lied!" and it would have appeared in Sports Illustrated.

V.

"So you think everyone is a narcissist?" No, but when you see elements of it, you can make some predictions.

Before everyone goes bananas, I am not judging Suzy Bass-- I'm not saying she is a good person or bad person. "Narcissist" isn't synonymous with "jerk"-- I'm using all of these terms to describe what I see, and make predictions about the future in order to help her and others like her.

The worst thing that can happen to a narcissist is a narcissistic injury-- in which their desired, constructed identity is revealed to be invented. In her case, it was literally fake, not just psychologically fake.

What happens in narcissistic injuries? Rage and violence. But, as a woman with limited targets for rage, it gets turned inwards: depression, suicide.

In 1995, when she was found not to have Hodgkin's disease she went into a psych hospital for several weeks. And, eventually, she had to move-- new location, new relationship, maybe even a new "identity"-- but for sure you don't stay put, exposed to everyone.

At her second job in Dallas, GA, where she was found to be faking stage II ductal breast cancer, she was able to get away and find refuge at her parents house-- where her parents still believed she had cancer. Identity intact.

She eventually went to Knoxville, where she got the math teacher job and ultimately was exposed again, this time also to her parents. Now no solace anywhere.

Once she left Knoxville, Bass admitted herself into an Alabama psychiatric ward and she told doctors she no longer wanted to live.

The Munchausen is wrong, not because it's formally wrong but because it is incomplete, in the same way as saying "it's a thirst disorder" when it's diabetes. If people are watching for "medical lies" as a clue to her condition they will inevitably miss the next set of non-medical lies and, importantly, the suicide attempt that is likely to result if those are exposed.

The problem isn't that this is a woman faking medical illnesses. The problem is that this is a ghost, and it's faking an identity. There are a lot of Suzy Basses out there.

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http://twitter.com/thelastpsych