May 27, 2009

Ramachandran's Mirror

And I don't like what I see.

For three years I had been seeing her for  "Major Depressive Disorder" and been treating her with Effexor and Restoril and thought I was doing a good job of it, too.  Proud of myself, you see, that I had reduced her symptoms AND managed to keep the number of pills she was on to well under the psychiatry average of 19.  I rule.

Also and by the way, she had an above-elbow amputation from a bus accident ten years ago.  She had phantom limb pain, in this case feeling that her missing hand was bunched up into a fist, cramping.  Occasionally, she'd even get a charlie horse in the forearm which wasn't there.

Sometimes if she was distracted, or if she distracted herself, the pain would go away.  Other days, it was terrible.

etc, etc, you get the idea.

The New Yorker had a recent article on Ramachandran, the neurologist famous for discovering that phantom limb pain wasn't the result of damaged nerve endings in the stump, but of a brain malfunction: the brain had rewired itself to think that a stump was there.  What needed to be done was to teach the brain that it wasn't there; or, more immediately, trick the brain into relaxing the fist that isn't there.  

He did this by putting a large mirror in front of the person, facing/reflecting the good arm.  Looked at from that side, it looked like you had two good arms.  You would then clench and unclench your "two"  fists, and you/your brain would "see" the other hand (that wasn't really there) also unclenching.  You'd feel as if the fist was relaxing, and the cramp would go away.   Apparently, the results were sudden and profound.



I was a little nervous, I don't mind telling you this up front.

I set up the mirror just as Ramachandran had described.  At first she didn't really get it, she wiggled her fingers, and nothing was happening.

"What I want you to do," I ad libbed, "is look in the mirror, and imagine that your left hand is doing the exact same thing as your right, simultaneously."  I showed her by opening and closing my fists.  "In other words, open and close both of your fists."

I barely finished my sentence when her eyes popped wide.  "Oh my God.  Oh my God."

My eyes popped open, too-- it actually worked!

We did that for a minute, and I asked her to then play a scale on an imaginary piano, 1-2-3-4-5-4-3-2-1, with "both hands."

She started crying.  This isn't an exaggeration.   "I can't believe this.  I can actually feel my hand..."

This, I thought with immense pride, is awesome.


Well, it's a wonderful story, I guess, and if this was the end of it it would be suitable for Good Housekeeping or maybe one of the medical journals that we pretend to read.  Maybe I could sell the story to TV. A Lifetime Original Special: Reflections Of A Physician.

But it's not the end, there are some hard questions to be asked that no one will ever ask:

Sure, it worked, sure, she feels better, sure, she thinks I'm awesome.  Why did it take me three years to try something I had known about for ten years with her?

Ramachandran's mirror technique is medical school stuff.  Everyone knows it.  Everyone.  If you don't know it children on the street kick you in the shins.  If you were in a coma during medical school then you still would have picked it up from a trillion other places, from Scientific American to Discover to Time Magazine.

Of course I knew the significance of the mirror.  Of course I knew how to do it.  I just never did.  It never even occurred to me to do it.

The mirror occurred to me; doing it never occurred to me.  I'll tell you that every single time I saw her stump, the theoretical implications of Ramachnadran's mirror immediately came to my mind, I imagined the mirror.  But I never tried it.

Not just me, but it also never occurred to the ten years of doctors she'd seen in her life.  Absolutely every single doctor knows about the mirror.  Not one tried it.

And it wasn't that I was lazy or didn't care-- I had tried Elavil, Neurontin, Lyrica, Cymbalta-- no, I didn't expect much from them, but I tried them, I thought, why not?  Maybe it could help?

But I never even considered using the mirror.

I can't understate this: I was thinking about the mirror in her presence, but never thinking about using the mirror.  I wasn't asleep, I wasn't drunk, I wasn't inattentive, I wasn't bored.  I was just too much in my world.

So I ask you: did I help her?  Or did I make her suffer needlessly for three years?


Without ducking responsibility, what's wrong with medicine today is that it is predicated on providing treatment, not on reducing suffering.  Not on solving problems.

The reason it never occurred to me to use the mirror is because the mirror is not something doctors do.  Never mind it is fairly safe.  What we do is offer treatments.  Medications.  Procedures.  Not maneuvers.

Do you know what every single one of my patients who lives in Flavor Country have in common?  They're on Lipitor.  That's what doctors do when confronted with the results of smoking.  Not nicotine patches or wellbutrin or talking them through becoming a different person.  They treat the results.  The smoking is an afterthought.

Think about how much controversy there is over using medications that are already approved off label for something else.  Where, then, is the cognitive strength to do something that isn't even considered a treatment?

Most residents fantasize about doing something like the mirror on a patient, partly because it sounds cool, but unfortunately really because it puts them on an equal footing with their supervisors.  They'll never know as much about Treatment Guidelines For Bipolar XVI as their supervisors, but they can know more about this.  This is how they can distinguish themselves.

Once they grow to the point where they are knowledgeable about the Guidelines, then there's no reason to use mirrors.


Also-- and again not to minimize my own responsibility-- part of the problem with all of the popularizers like Oliver Sacks, NPR, The New Yorker, is they trivialize the information to the point of uselessness.  "So that's why the Kurds hate the Sunnis!  I'll have a latte."  There's a sense among doctors that if it appeared in, say, Wired, it's not real medicine.

When I was a resident I tried the Sacks insights. None of them ever worked.  It wasn't either of our fault: there's a big gap between practicing medicine and watching Awakenings.

What I didn't do, of course, is watch Awakenings and then go back and research how I might actually apply it.


Now, all you patients, think about this: there is more than a slight chance that your doctor knows how to help you, but isn't trying it.  Maybe it's another medication, maybe it's an intervention, maybe it's information he's simply not telling you.  Not on purpose-- it doesn't occur to him to tell you.

Not because he's bad, of course.  I don't think I'm bad, not a bad doctor anyway.  But hell, if I had to sit with every patient and think out of the box on every issue with them, and individualize the treatment while still maintaining scientific rigor-- drawing not just medicine but from all possible fields that might be applicable to the current problem, being "conscious of the patient's spirituality" not because that's what doctors are supposed to pay lip service to, but because I might be able to use it in a clever manner to obtain results, spending time proportional to what is actually going to matter (like smoking) and less on treatments I am conditioned to provide reflexively--

-- then what kind of a doctor would I be?


I think you'd be a good doc... (Below threshold)

May 27, 2009 8:48 PM | Posted by information addict: | Reply

I think you'd be a good doctor, but probably broke, unfortunately.

What I can't stand is when doctors brush off patients who come in with "novel" or new information on a cause or a treatment for a problem, because its outside the doctor's experience and training (even if they do have 30 years experience). Its just not what they want to hear because of course, how could that patient possibly know more than they do? God forbid you mention you learned something on the internet. You have to walk in with a medical text book and then they think you're nuts (even if you're right). [Took me years to find out I have celiac.]

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Sigh. Long sigh. I think ... (Below threshold)

May 27, 2009 11:10 PM | Posted by AnotherPsych: | Reply

Sigh. Long sigh. I think plenty outside the box in my practice. (Or: I practice outside the rote and unquestioning lockstep of my peers.) Lately I've run into much more push-back from my patients than I ever anticipated. They come to me on Depakote with a diagnosis of Bipolar VII, and I suggest that their distressing feelings may come from something other than bipolar, and by the way, the medication that's making you fat and bald may not even be helping... Many people push back. Hard. They seek the comfort of a medical solution to their problems, since it's a convenient externalization. ("It's not me, it's my bipolar.") They only want another traditional treatment, usually a medication, which naturally doesn't work, but does have the rather significant advantage of allowing them to blame me for suggesting the wrong prescription. Or withholding the right one. ("I read online that adding a thyroid hormone helps. And Ambien. And Ritalin. Why won't you do that for me? It's your fault I'm not getting any better.")

Of course, I'm not suggesting that the Mirror wouldn't work for the patients who buy it. I am suggesting that many patients have a need to think inside the psych "box" too. They need the diagnosis, the meds, the traditional interventions, the Depakote, the Lipitor. They need that, because the Lipitor doesn't ask them to change who they are ("a smoker"), just a condition they have ("high cholesterol").

Likewise, the Depakote doesn't ask them to change who they are ("a person chronically disappointed with their accomplishments and their relationships"), just a condition they have ("bipolar").

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Basically everyone on earth... (Below threshold)

May 28, 2009 1:13 AM | Posted by crumbskull: | Reply

Basically everyone on earth, regardless of their profession thinks and acts this way at their job. Whats interesting is that it seems significant when you identify it in doctors. Like this is a surprise to us. Think about how you act your job, think about how your friends act at their jobs.

I work in the service department of a motorcycle shop. In about fifty percent of bikes the mechanics work on they fuck around with the brakes. A single un-tightened bolt on a brake caliper can cause your brakes to stop functioning. Which means that about fifty percent of the customers who come to us for service literally leave their life in the hands of our mechanics. The same goes for auto mechanics. For the average person, your health is dependent far more often on the performance of your mechanic than your doctor. And yet, think about how you visualize a mechanic. Compare and contrast that mental image with the one you have for doctors.

Its all just people, doing a mediocre job to make sure they can keep paying for rum.

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Now you have me wondering w... (Below threshold)

May 28, 2009 3:29 AM | Posted by Charlotte: | Reply

Now you have me wondering whether there's a cognitive equivalent of attentional blindness. I think there is, and I think I know which book, the color of the cover, a fairly close approximation of its location in the library, and I would recognize the author's name.

The library is 5000 miles away. I have the wrong retrieval cues for the situation.

The mirror effect relies on a synchronized temporal pattern of sensorimotor inputs (plus the absence of contrary info from the missing limb). There are now a number of experiments with normal participants demonstrating equally compelling effects with somatosensory or sensorimotor input (and no imagery, but imagery has similar if weaker effects on cortical activation).

I also read the Ramachandran articles (in academic journals), and the problem is they described the phenomenon but did not explain why it occurred. In certain respects Ramachandran is an amateur. The principles of what was happening came later. The existence of principles distinguishes whether something might be categorized as a parlor trick or should be considered a repeatable procedure.

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What kind of doctor would y... (Below threshold)

May 28, 2009 12:32 PM | Posted by Anon: | Reply

What kind of doctor would you be? You wouldn't. You'd be a private school teacher. :)

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Private school english</... (Below threshold)

May 28, 2009 5:39 PM | Posted, in reply to Anon's comment, by Colin: | Reply

Private school english teacher.

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"The existence of principle... (Below threshold)

May 28, 2009 8:12 PM | Posted, in reply to Charlotte's comment, by Ben: | Reply

"The existence of principles distinguishes whether something might be categorized as a parlor trick or should be considered a repeatable procedure."

I may be involved in a different kind of science, but I'm pretty sure the key factor in finding out if something is a repeatable procedure is... does it work when it's repeated? Theory is nice, but thankfully things that work work independent of whether we understand them.

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Umm, speaking of doctors an... (Below threshold)

May 29, 2009 6:36 AM | Posted by Mintyfresh: | Reply

Umm, speaking of doctors and their abilities to treat people, here's a link

A basic summary of the article is that it is difficult and unrewarding to treat narcissists but narcissists create victims who in turn power the mental health industry.

A quote

"The narcissist refuses to believe that he's sick and refuses to cooperate, but these people trust you and can easily be persuaded that something is wrong with them (so long as you say it with a sympathetic look on your face) and will conscientiously cooperate to improve themselves by going along with whatever you say. Indeed, if nothing else, they'll experience a placebo effect"

It raises in interesting point.

Are narcissists profitable to the mental health industry?

It's tone is bitter and doctor blaming, but I think that's because most people who are abused by narcissists, are guarded and bitter for protection.

Also wanted to share this

How to communicate with narcissists

I know this isn't exactly on track, but there is a lot of talk on narcissism here and I wanted to offer something productive.

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I'm more curious as to why ... (Below threshold)

May 29, 2009 10:02 AM | Posted by Joseph Bergevin: | Reply

I'm more curious as to why the woman herself didn't know about the mirror technique. As you've said, it's been in numerous popular media. As someone with a missing arm and the associated phantom pain, you'd think this is something she would have either noticed, researched, or at least been told about by a friend. It's a simple procedure, reproducible by anyone.

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Very interesting article, b... (Below threshold)

May 29, 2009 3:04 PM | Posted by Matt Wigdahl: | Reply

Very interesting article, but you didn't answer what to me is a more interesting question: What caused you, after 3 years of thinking about the procedure but never considering actually trying it out, to finally decide to use it?

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"I may be involved in a dif... (Below threshold)

May 30, 2009 7:43 PM | Posted, in reply to Ben's comment, by Charlotte: | Reply

"I may be involved in a different kind of science, but I'm pretty sure the key factor in finding out if something is a repeatable procedure is... does it work when it's repeated? Theory is nice, but thankfully things that work work independent of whether we understand them."

Yes, repeatability is the key. However, unrecognized differences in the experimental paradigm can produce differing results. This may be less true in other fields but is an issue in behavioral (and brain imaging) studies. Sorting out what elements of the paradigm are important is part of the development of an understanding of the effect produced. An explanation that includes a mechanism, whether psychological or biological, is preferred over one that doesn't, for the rather simple reason that it makes it easier to replicate the experiment.

Perhaps your field has a different model of what a theory is. In cognitive science, a theory is an explanatory and predictive construct, but most are an abstraction of and extrapolation from available data, not derived de novo from fundamental principles.

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That's exactly why I like t... (Below threshold)

May 31, 2009 12:03 AM | Posted by Linda: | Reply

That's exactly why I like to go for a diagnosis and then research things holistically. As a patient I am tired of doctors who don't know my name and just write out prescriptions. Our health care system needs to be more than tired doctors with massive amounts of patients. When I asked my doctor for more than a prescription, he said he only had 13 minutes per patient and didn't have time for more.

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As you write (unfortunately... (Below threshold)

June 1, 2009 2:53 PM | Posted by System MD: | Reply

As you write (unfortunately true), we MDs are sickness treaters most of the time and healers too little of the time. The number of examples are legion from psychiatry to surgery. We know to treat causes not symptoms, then cry 'we cannot treat the cause (obesity, say) so we operate or give Rx's or both.

Under current "system" we do better financially by treating sickness than creating wellness. What if system paid us for making/keeping our pts healthy?? If you view healthcare as infrastructure ( and acted like a good CEO (, there would be appropriate incentives and our behaviors would change. What do you think?
Deane Waldman, System MD

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Unfortunately, the physicia... (Below threshold)

June 2, 2009 6:22 PM | Posted, in reply to Linda's comment, by Anonymous: | Reply

Unfortunately, the physician gap is getting worse...less and less of the younger generations have the discipline or rigor to choose the path of a doctor. The physician gap will be something like 130,000 in the next 20 years.

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"I also read the Ramachandr... (Below threshold)

June 4, 2009 3:24 PM | Posted by george: | Reply

"I also read the Ramachandran articles (in academic journals), and the problem is they described the phenomenon but did not explain why it occurred. In certain respects Ramachandran is an amateur. The principles of what was happening came later. The existence of principles distinguishes whether something might be categorized as a parlor trick or should be considered a repeatable procedure."

Then you ought to read some more articles, because it's about neuroplasticity. Ramachandran has an MD and a PhD; it was a shot in the dark, but when it worked, he understood the principles (in Phantom Limb patients, one region of the Penfield map is invaded; visual feedback provided by the mirror overrides this). A good doctor doesn't let his ego get in the way of his appreciation of an effective treatment.

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This was written timely for... (Below threshold)

June 4, 2009 7:01 PM | Posted by ITW: | Reply

This was written timely for my own personal situation. Thanks.

In your own case, perhaps the issue wasn't that it didn't occur to you to try the mirror, but perhaps the issue was that you didn't realistically think it could work as well as it did? Hindsight is 20/20. If the mirror trick worked this well in EVERY case, I do think it would be a first line treatment for phantom limb issues. You took a risk when you attempted the mirror. If it didn't work, you would look bizarre and quackish. Failed medications carry minimal risk to the physician's reputation/ego (assuming they are approved for the condition being treated). Failed "experiments" like this can make a doctor look and feel like an altie nutjob.

I suspect a lot of the reason doctors don't do stuff like this more often is that it is a lot of emotional effort to take such a risk. There is no personal/professional risk of using standard medications (even if your hunch is that it won't help). There is much more risk with using alternative techniques, for numerous reasons. Reason one being yea, you look like a quack when it doesn't work. It's a blow to personal and professional ego. Reason two being your patient is like "WTF, this is not standard therapy" and doctors can get in trouble for doing unconventional things sometimes. It is professionally threatening.

And, of course, it is more effort to do unconventional things. It is easier - and safer - to go with the flow. The flow is dictated by pharmaceutical companies as pharmaceuticals are money makers. SO the flow is dictated by money. And it is easier to go with the flow.

But, in your own case, I do suspect a big reason you didn't try the mirror earlier: you weren't sure it would work and this carried an ego risk (because it was an unconventional therapy). In hindsight, wow why didn't you do it sooner.

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Hey AnotherPsych-I'm... (Below threshold)

June 4, 2009 7:12 PM | Posted by ITW: | Reply

Hey AnotherPsych-
I'm curious re: your approach to patients diagnosed with bipolar VII on depakote. While I haven't filled my depakote prescription, I do suspect my bipolar II dx is bullshit (partially my fault, as I am the one who went to a psychiatrist in the first place).

Unlike the hypothetical patient you describe who WANTS to be bipolar, at every session with my doctor I asked her to give me alternative diagnosis/explanation for my symptoms. Perhaps they weren't symptoms at all?

Repeatedly I raised the idea that maybe I just need therapy.

She told me I was too "unstable" for therapy and said I did have symptoms that required medication. Was she right? I don't know. I was depressed as hell most of the past 2 weeks. I am starting to feel better now. Do I need medication? Maybe. I'm not taking any right now.

So, as a patient, I kinda take offense at your "it's the patients who don't want to change" attitude. This patient when to her doctor and every single meeting asked the good doctor if I just needed therapy to work on issues and stuff... if my diagnosis of bipolar was right... Every single time the doctor said I needed medication.

A lot of the problem is the psychiatrists, and not the patients. Maybe the patients are so resistant to your suggestions (that some of the problems are situational and not mental illness) because these patients have a long history with doctors who attribute everything to mental illness and they have been conditioned to stop taking responsibility for anything at all?

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Also for AnotherPsych...</p... (Below threshold)

June 4, 2009 7:21 PM | Posted by ITW: | Reply

Also for AnotherPsych...

I found your reply rather offensive, as a person who is uncertain about my diagnosis and often with a strong feeling of guilt for my life situation... and I'm not even your patient! Perhaps a better reason patients resist you so much is because you phrase things in an unempathetic way, which exacerbates any preexisting guilt/distress feelings experienced by the patient.

Maybe if you approached your patients with a more constructive / understanding attitude they would be more amenable to any suggestion that some problems are related to thought patterns/behaviors and not to "bipolar". And, maybe, if you offered them some kind of solution (how do you change your thoughts/behaviors?)... a therapist or something.

At least depakote offers hope. Being told you are a failure and it's your fault kinda doesn't.

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ITW, sometimes a patient ne... (Below threshold)

June 20, 2009 4:23 PM | Posted by hmm: | Reply

ITW, sometimes a patient needs to have the cold, hard truth gently broken to them. I know it's not comfortable to hear that one's condition is self-inflicted, but understanding and accepting that is the first step towards solving it.

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Medicine is fundamentally a... (Below threshold)

June 20, 2009 4:53 PM | Posted by Dave F: | Reply

Medicine is fundamentally a trial and error process. Right now the price we pay for errors is expensive. Unless we give the medical science more chances to make errors we will not go forward. The system has become so rigid that even simple mirror techniques are not tried first before trying every expensive drug out there. Imagine if the money she spent on trying various drugs for 3 years had been indeed spent on science, physical and mental treatments, and research, we'd be in a lot better shape as a profession.

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Mr. Ramachandran did a 20 m... (Below threshold)

June 20, 2009 5:38 PM | Posted by Tore: | Reply

Mr. Ramachandran did a 20 minute lecture about this mirror at the annual TED conference. A video recording is available here.

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I read some of your posts w... (Below threshold)

June 20, 2009 6:46 PM | Posted by Ché: | Reply

I read some of your posts well over a year ago, and to me you seemed like someone firmly rooted in the bias of their training. Yet another arrogant psychiatrist convinced they know better than the patient. I am extremely excited after reading this post. It looks like you may be flirting with becoming therapeutically oriented, rather than treating people like a complex but sterile chemistry set.

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I blame it all on omniscien... (Below threshold)

June 21, 2009 9:40 AM | Posted by Mike Hunt: | Reply

I blame it all on omniscient tv doctors.
People tend to apply a solution which works thirty percent of the time to one hundred percent of all problems. If you have a hammer every problem looks like a nail.
TV doctors come along and view each case individually. They see something other than the "norm". Then using deduction or Occam s Razor actively seek answers.
Of course that is only tv right?

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As I understand it, mirror ... (Below threshold)

August 5, 2009 4:53 AM | Posted by Anonymous: | Reply

As I understand it, mirror therapy now has serious medical publication behind it and is standard procedure for lower limb amputees at Walter Reed. See Jack Tsao's study in the New England Journal of Medicine:

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I read about mirror therapy... (Below threshold)

August 13, 2009 3:25 AM | Posted by Jeisea: | Reply

I read about mirror therapy in my search for non drug ways to deal with pain etc of Complex Regional Pain Syndrome. I worked out what made sense and used an ordinary home mirror. It worked and continues to work for relieving and eventually stopping pain. I devised a way to treat mouth pain with a hinged double makeup mirror. It worked very well but soon after pain was gone it returned. Turned out I had an abscess and ended up losing my tooth because mirror therapy worked so well. It was only out of frustration about pain returning that I went to a dentist. Mirror therapy works for pain, not just phantom limb pain. Chronic pain changes the brain. Mirror therapy clarifies the neurotag (see Expalin Pain by Dr Lorimer Moseley and David Butler

It is not important that you took a while to try this simple very effective, drug free way of stopping pain. What matters is that you did try it. What also matters is that you are promoting awareness withing your community so many will benefit.

Mirror therapy seems a bit gimmicky and until recently hasn't had scientific rigour behind it. There are other non drug, very effective treatments which are little known and used. I am in remission as of some a few months ago due in part to mirror therapy. I had a whole body problem with dysautonomia. I went to an Indian GP who used Yamamoto New Scalp Acupuncture, devised by an anaesthetist to treat stroke and neuropathic patients. YNSA involves a microsystem, cortical representation of the body in the brain just as the pictures you see of Ramachandran's body in the brain. After five treatments I no linger had dysautonomia, no paroxysmal atrial fibrulation, no extremely labial BP with Syncope, no shortness of breath with exercise etc.

I encourage you to continue to "think outside the square" and congratulate you on speaking out about your discovery.

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What kind of doctor would y... (Below threshold)

August 23, 2009 10:11 PM | Posted by Glenn : | Reply

What kind of doctor would you be? A clinical psychologist, perhaps?

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Im citing this posting in D... (Below threshold)

September 17, 2009 3:52 PM | Posted by Anonymous: | Reply

Im citing this posting in DailyKos tonight as part of our ongoing Thursday night health care series ... and my premise is that if mirror therpay can work for visual pain, why then cannot we use it to treat conditions like severe depression by creating the illusion of a self which existed prior to the onset of the illness and thus 'trick' or 'reset' the mind .... My theory (relying on sachs, Ramachandrian, Proust and findings about memory storage and retrieval involves immersing individual in a multi-sensory experience ...evocative smells, tastes, music, clothing, touches, from times in their past which were pre-symptomathic or inter-episodic, full length mirror, use of camera or double mirror to present a 'phantom self' , then retrigger ..... I'll send you the url but if by any chace you get any time to comment prior to 6pm PSt tonight, I'd love to include your ideas....

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This document might interes... (Below threshold)

October 11, 2009 10:01 PM | Posted by jeisea: | Reply

This document might interest the last commenter. It lends weight to the idea of using a mirror (or other brain retraining technique) to relieve various symptoms of a number of diagnosed conditions.

Personally I suggest it could go further and that retraining the brain could stop messages of inflammation as in arthritis, stop messages to grow inappropriately as in cancer, stop messages to attack the immune system.

The similar responses from various different brain retraining techniques suggest that it's wise to be open minded and not exclusively consider one method.

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You'd be a psychiatrist.</p... (Below threshold)

September 20, 2012 8:38 PM | Posted by kiddink: | Reply

You'd be a psychiatrist.

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Thanks for the strategies y... (Below threshold)

April 29, 2013 11:39 PM | Posted by Michal: | Reply

Thanks for the strategies you have discussed here. I believe there are several qualifications that will can't be ignored when looking for a local dentist.

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