The spectrum of neuroses

Neuroses as defined by conflicts can be normal in a person during a period in which decisions are required. When the choice is needed between two different paths. They become a problem sometimes though. Horney describes the following characteristics of neuroses which tend to become a problem.
-They are incompatible with each other. Both alternatives to a decision are avoided.
-If looking at them spatially a normal conflict will be 90 degrees to each other where as a neurotic conflict will be 360 degrees to each other.
-A conflict will have both alternatives that can be valued but in a neurotic conflict both alternatives will be abhorred.
-If any conflict plays itself on two poles, the two poles will be more polarized in a neurotic conflict.
-The stakes will be higher when a neurotic conflict is concerned.

Balint describes the malignant and the benign fault. It almost sounds like that is what Horney observed. Balint however put the causes of the fault as development of an individual. A fault in the preverbal stage caused a malignant fault which caused the organism not being able to conceptualize the conflict in words.

It would seem that Horney and Balint talk about swinging on a pendulum which seems to address two different dimensions in two different planes.

Speech problems

Recently while evaluating a child with speech problems, the parents mentioned whether the child had apraxia or not. What ensued was a discussion in which neither the parents nor myself knew what we were talking about. To add to the confusion, my hippocampus had thrown out several associations to apraxia of speech, like dysarthria, phonological disorder and aphasias. Doing an internet search compounded the difficulty just as asking various people did. Everyone answered something that they were not sure about and soon my head was swimming about their differences. Luckily I found an article in Neurocase (2005) 11, 427-432 by Ogar et al.

APRAXIA OF SPEECH: Impaired ability to coordinate the sequential, articulatory movements neccessary to produce speech sounds is called apraxia. Articulatroy erros and prosodic abnormalities are hallmarks. Signs include effortful trial and error grouping with attempts at self correction, persistent dysprosody, articulatory inconistency on repeated productions of the same utterance and/or obvious difficulty initiating utterances. Vacular lesions, trauma, tumors can cause this. Apraxia of speech is also the first symptom in neurodegenerative diseases such as corticobasal degeneration or non-fluent progressive aphasia.

CONDUCTION APHASIA: Result of damage to communication between Wernicke and Broca. This communication is through extreme capsule and/or arcuate fasiculus. Speech is fluent, comprehension is good but oral reading is poor and major impairment in repitiion. Many paraphasias occur and transpositions of sounds within a word also occurs (television -> velitision).

BROCA'S APHASIA: In this the speech is understood, and the all the levels of speech planning are intact except for motor execution which is not intact.

(Apraxic speakers are believed to select the correct phonemes, only to have trouble with their motor execution; People with conduction aphasia typically speak with near normal prosody, whereas halting effortful speech with abnormal prosody. They may also lack awareness of their speech errors and therefore may not always make attempts at self correction while the opposite is true in cases of apraxia of speech)

DYSARTHRIA: Dysarthria is caused by impairment of muscle strength, tone, range of motion and/or coordination. It can be caused by UMN or LMN lesions of the cranial nerves.

(Errors heard in dysarthric speech are typically consistent and predictable, while the speech errors heard in apraxia of speech tend to be highly irregular. Sound distortions, prolonged segment durations (e.g prolonged vowels or consonants) and prolonged inter segment durations (e.g. abnormal pauses within sounds, syllables or words) are characteristic for apraxia of speech.

PATHOPHYSIOLOGY OF APRAXIA: Van der Merwe's model of speecch planning and programming says that initially, basic linguistic units or phonemes are selected. During a second motor planning phase these phonemes are organized into temperospatial codes for speech production. In the third, motor programming phase, muscle specific motor programs are selected and sequenced before moving forward to fourth phase when these sequences are carried out by the speech musculature. Apraxia of speech is caused by problem with second phase.

TREATMENTS: For mildly apraxic patients, poor prosody may be the primary speech deficit and therefore, goals designed to improve intonation and stress. For the moderately or severely apraxic patient, therapy might focus on relearning oral postures for individual speech sounds.
-PROMPT uses rate and rhythm control strategies
-Wambaugh and colleagues use remediation of misarticulated consonants through modeling repetition of minimally contrastive words, graphic cues and phonetic placement cueing.

Dreams

Shani says:
"I say dreams are a mechanism of the mind to test any changes it makes to the model of the world (in our head), while we sleep.Say i watch a documentary on snakes. I already have a section on snakes in my head (part of the model of the world around me) that has all the 'relevant' information i have collected on snakes so far. Owing to what happend during the day, while i lay in bed and sleep, my mind goes to work to extract the new data (or extent of emphasis on old data/rules), and then wants to suppliment the old notion of snakes with the new data ... as it does that it needs to verify whether that change is good, i.e. wouldn't lead to me say getting bit by a snake cuz i stepped on it. So to verify, the mind creates a drama and lets my updated model react to it, i might see myself in a jungle and then a snake and the mind carefully monitors my reaction to it ... if everythign goes smooth, good, if not then maybe the changes weren't quite right ... "

I say:
"I think there is the biological and then there is the psychological function of dreams. It is not clear whether the dreams play a homeostatic role in our lives, meaning that they create the balance, re orient us and bring us to the center of our biological or our psychological lives.

I think you are right about dream being the censor for the change that occurs in our minds. I would though want to extend it by saying that introducing snake as a data in the mind means introducing various things in the mind. I would liken it to the mind going over the translation of the world that it did in the day time. I would think that is what you mean by going over the data.
The translation though would be a tricky thing because that would mean what is the data that the mind sees.
If I were wearing red spectacles I would interpret all data about colors as various shades of red. So it is interesting how the mind interprets the new data. In gross terms new data is interpreted, associated and then stored.
In the example of the snake. You dreamed about the snake. Your interpretation of the snake, i would think is a very biological phenomenon which involves integration of the lines and the colors and then naming it by comparing it to past experiences. The comparing part starts to spill over in to the psychological realm. Now when you compare it, the emotional significance of the snake will be brought forth. Freud felt that unconscious mind or the dreaming mind is involved with primary thinking. Thinking that would use primitive patterns of reaching conclusions. (See level I and level II defences). There are some bizarre explanations for a snake incidentally. Snake has been interpreted as a phallic symbol and the explanation is that the mind while associating it might recall a similar emotion (the one that the person might have felt on seeing a snake) associated with a similar form. Ofcourse there is a lot of "static" also going on in terms of defences and the resulting situation is bizarre dreams which need to be interpreted.

Dyslexia

Dyslexia: A specific reading disability due to a defect in the brain's processing of graphic symbols.

Dyslexias are characterized by their characteristic hemishperic deficit.
Pirozzolo (1979) and Pirozzolo and Hess (1976) suggest that there are two fundamental types of dyslexia: auditory-linguistic dyslexia and visual-spatial dyslexia. Persons with the former exhibit difficulties in the verbal and language area, have naming problems, and are slow in carrying out any types of verbal tasks. The persons with the former struggle with visual perceptual difficulties. Bakker (1973; 1979; 1982; 1983) thinks about different approaches to reading. The linguistic-auditory group uses their left type hemishphere hence called L-type dyslexics. The visual dyslexics have a difficulty with perceptual requirements in word representation and use the disorder stems from right hemisphere, hence the term P-called dyslexics. The same kind of differentiation is meant by the the words dysphonetic(auditory problems) and dyeidetic dyslexics (visual problems). Hemishpheric EEGs also show preferential brain activation with the different types of dyslexics.

Prigogine: the end of certainty

In his book, the end of certainty, Prigogine talks about irreversibility as a possibility. This is something that people have neglected when putting forward laws that describe how nature operates. He calls many laws deterministic in nature, in that, they can be bidirectional with respect to time. He however says that this bidirectional time is a very narrow minded view. It only takes into consideration the isolated experimental subjects and considers them free of the multiple other factors that are impacting on them.

I was involved with a functional behavioral analysis of a child with disruptive behaviors. In a functional behavioral analysis one tries to determine the antecedents that cause the behaviors and the consequences that either enforce or extinguish the behaviors. A hypothesis of the whole situation is made and that hypothesis is tested out. The parents are then given strategies to manage the behaviors from the hypotheses. The proof that those strategies work has been shown to the parents during the testing phase. Hypothesis like "the child can go to a non preferred activity if he knows that it is time limited and if it is followed by a preferred activity", is an example.

This kind of analysis of behaviors is fine if a behavior is only considered to be present and influenced by a limited number of antecedents and consequences. But the truth of the matter is that the true antecedents to a behavior are multiple and have a propensity to be unknown. Freud believed the majority of the decisions that a person was making were unconscious. When dealing with these many possibilities of environmental and psychological variability, it is essential not to "over simplify" or "over complicate"things to the point that incredulous demands be made of patients in "treatment".

Prigogine talks about phase space which would be very applicable to the scenario of the disruptive child. All the different possible behaviors of the child are represented in that phase space. Prigogine also talks about stable (determinism) and unstable (chaotic) equilibrium and details characteristics of those systems.

A beautiful example he uses is of Poincare who proved that dynamical systems are non integrable. An integrable system would be a static deterministic world without the possibility of freedom. Non integrability results from existence of resonances between degrees of freedom. What we have done with behavioral analysis is to put on deterministic glasses and translated the multi factorial world into a lesser dimension. The city of Oz was not really green.

Prigogine also talks about prevalent energies in a system. How potential energy is maximum in a state of equilibrium and free energy is at minimum in a state of equilibrium. Increasing energy in a system also increased the areas of randomness in it. He describes creativity as an irreversible phenomenon which has been associated with complexity. Any system in non equilibrium can spontaneously evolve in to increased complexity and any system in non equilibrium can lead to irreversible phenomenon, hence creation.

With this he comes full circle to creation as an irreversible process which creates a system of equilibrium for itself till of course it is pushed into non equilibrium again. It will get pushed into non equilibrium.

From this we glimpse a view of a world which is constantly oscillating in between equilibrium and non equilibrium. A world which is constantly changing due to chaos, organizing and disorganizing itself. And caught in the center is man who attempts to act like the universe, organizing and then disorganizing whatever it comes across. Creating and then uncreating. Cooking and then digesting. Being born and then dying.

Jungian archetypes in media

In a conversation today, I realized how the theory of Jungian archetypes has an association with the recent trend of going behind the mask of the superhero. In Hollywood movies the trend has turned from the behaviors of the superheroes to the motivations behind them. In all past cultures this has come at a certain point in their respective civilizations. The stories attributed to the gods are present in greek, roman, egyptian, hindu and virtually any civilizations. When religion clamped down on the muslim culture the stories about the life of mystics and pirs was born. It almost points to an innate need of a civilization to have stories about the ideals. As if the masses are trying to express their conflicts in the idealized figures that they try to emulate. This primordial need is manifesting itself in the the movies of the present also.
Batman from the times of George Clooney and Kilmer has suddenly a different mood now. Superman was explored in more detail in Smallville. Spiderman has definitely become more introspective. Star wars had to explore the origins of the dark side.
The point to notice is that the creators of all these characters had invented their past when they were brought to life initially. Spiderman's conflicts about being Parker and avenging the death of his grandfather are not new. Neither is Clark's search for his home land and the isolation that he feels new. But they were limited by the spread of the comic media. Now it is as if the whole world is re discovering these archetypes as the media reaches out to them.
There is ofcourse a finite amount of media or the interpretation of media that can be incorporated in an individual's mind. That amount of finite data, has a comprehensible number if we apply the bell curve to the human population. Neuropsychology shows us that all new information has to be interpreted, associated and then remembered. Hence within that bell curve there is all sorts of different combinations that exist. Some person might comprise his "moral good" as an expression of batman and superman, another might have a different combination. The result is a pallette of different colors that portray the internal unconscious life of an individual. Twinship to different archetypes as well as parental/environmental mirroring might also play an important part in selection of the colors that go to make a pallette.
A point to note is that people who do not watch movies are not necessarily bereft of this archetypal life. They just reach out and grab onto the archetypes that have been passed down from other sources like religion or ancestary.
Retelling stories and understanding them from different perspectives an important part of the human dillemma. Something that will continue in its myriad variations.

Psychic trauma in children: review of an article

AM J Psychiatry 138:1 January 1981 by Lenore C. Terr, M.D.

Background:
This article discusses the response to psychic trauma in children who were exposed to the kidnapping in Chowchilla.
The story of the kidnapping goes something like this: July 1976, 26 children (5-14 year) disappeared for 27 hours and they eventually escaped their captors. The school bus had been stopped by a van blocking the road and masked men had taken over the bus at gun point. The children were transferred to boarded over vans in which they were driven for 11 hours and then transferred into a "hole" (actually a buried truck trailer). The kidnappers covered the truck-trailer with earth. The children were buried for 16 hours until two of the oldest and the strongest boys 14 and 10 dug them out. By then the kidnappers had left the vicinity.

Methods:
The children were interviewed by the author and one or both of the parents had also been interviewed. The school bus driver and the kidnappers were not interviewed. This interview took place between 5-13 months.

Notes:
Initial signs of traumatic disruption (the breach of the ego):
-Omens: Children tend to associate things that happened before the incident and related that as the causal factor of why they were kidnapped.
-Fear of further trauma: Traumatophobia. (am I going to be killed?)
-Disturbances in cognition: During trauma disturbance in cognitive function such as perception, time sense and thought.

Repetitive phenomena (Repetition compulsion):
-Traumatic dreams: 1)terror dreams 2)exact repetition of kidnapped events 3)modified repetitions of kidnapping events 4)deeply disguised dreams
-Post traumatic play
-Reenactment: Direct reenactments of attitudes, fears or actions that have occurred before or after the kidnapping.
-Absence of flashbacks: Adolescents exhibited "voluntary" visions in contrast to the involuntary intrusive thoughts that adults have. Children younger than 9 did not complain of having visions. The ability to day dream develops after 9 and that might be the reason why children below 9 did not have flash backs.

Fears: (Kidnap related fears)
-All children had kidnapping related fears.

Personal Commentary:
Note that the DSM required criteria of a distressing event, re experience, avoidance and increased arousal are necessary for PTSD. Children in this incident also displayed re experience (exeplified by the repetitive phenomena), avoidance (is an end point of multiple psychological factors including omens and fears) and hyperarousal (exemplified by fears) .

Diagnosis of Tourette's Syndrome

Tourette's disorder is named after Gilles de la Tourette, a french neurologist who was a student of Charcot. He worked as his resident in Salpetriere, Paris. Charcot named this disease for his resident when Tourette published a case series of nine patients with Tourette's syndrome. Previously thought to be rare, it is now thought to be a spectrum disorder with neuropsychological sequelae. Incidence ranging from 1-10 per 1000. Tourette's is a disorder which poses as many different things and is usually misdiagnosed with many things before it is correctly diagnosed. The DSM IV TR criteria for Tourette's are:

A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.)

B. The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.

C. The onset is before age 18 years.

D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or post viral encephalitis).

As per criteria it is useful to screen patient's for tics but sometimes it is also useful to keep a flexibility to go the opposite way, i.e, look for a particular type of a personality and then look for tics. The typical tourette's personality reflects the development of individuals in a certain way. Individuals with Tourette's have problems with inattention, hyperactivity, anxiety symptoms, obsessive thoughts, compulsive actions, stubbornness, mood swings and tics. The development of Tourette's children is probably parallel to the development of a child without Tourette's because of the fact that people with Tourette's can be found in all walks of life.

Some people call the associated features of Tourette's as co morbid diagnoses. Anxiety disorders, ADHD especially inattentive type and Cyclothymia vs Bipolar can be seen. So searching for tics once seeing a constellation of symptoms as above can be helpful.

The paranoid dynamic and mindfulness

Paranoia consists of individuals projecting on to other objects their unconscious desires or motives. There is a certain amount of a paranoia existent in every individual and there are a good number of people who have more of this trait than other people. According to the DSM-IV-TR, between 0.5% and 2.5% of the general population of the United States may have PPD, while 2%–10% of outpatients receiving psychiatric care may be affected. A significant percentage of institutionalized psychiatric patients, between 10% and 30%, might have symptoms that qualify for PPD.

Paranoia is sometimes used to cope with intra-psychic conflicts. When used like that it is called a defence in classical pshychoanalytical literature. For example lets consider a person who does not like a certain sweater and wants to destroy it while it is hanging on display in the shop. For the sake of appropriateness he will inhibit that impulse and by inhibition will give rise to an intrapsychic conflict. This conflict will become more and more strong as the impulses to destroy this sweater increase because of the opposite tendency which is in harmony with not doing anything inappropriate while looking at sweaters in the shop. Now let us consider the shop manager who to help out this person looking at sweaters in the shop comes over and starts hovering around. This person who has been thinking of destroying the sweater will project on to the manager. Now he will feel persecuted by the manager and feel that the manager is expecting him to destroy the sweater and that is why he is hovering around him. This will lead to paranoia on the part of the person who is browsing the sweater line up in the sweater shop.
If people use this defence exclusively it results in a certain type of a personality called the paranoid personality disorder. People described as having a Paranoid personality employ other defences also but we are foucsing on the paranoid dynamic.

In clinical situations it is proscribed that dealings with these individuals should be follow certain rules.

-It is important to hide as little as possible from these individuals. This transparency should include note taking; details of administrative tasks concerning the individual; correspondence; and medications.

-Individuals with paranoid tendencies often don't have a well-developed sense of humor; those who must interact with people with PPD probably should not make jokes in their presence. Attempts at humor may seem like ridicule to people who feel so easily threatened.

-Asking about an individual's past can undermine the treatment of PPD people. Concentrating on the specific issues that are troubling the patient with PPD is usually the wisest course.

-The paranoid thought should not be challenged too directly.

The basic proscription is because of the following dynamic. The paranoid dynamic vascillates in between two extremes. The model of the two extremes is useful for a number of dynamics and the etiology of defences (from Level I to Level IV), Gustafson has called these extremes the near-far dilemma. On one hand is the threat to be engulfed in the closeness which is too uncomfortable and on the other hand is the distance which threatens total isolation and loss of touch from reality.

So with a health care provider there is a dance which the paranoid person engages in. If the clinician is not quick on his/her toes they can soon find themselves out of rhythm with the interview. The above general rules serve well but it is to be kept in mind that rules are made for people and not vice versa.

"The unfettered mind" which is taught in everyday mindfulness is needed in many things including dealing with this trait/defense/jinn described above.

The Secret

A lot of commotion has been occurring in the new age thought circles about the secret. This is how I understand it. I made this opinion after religiously following Dilbert for several years.

Entropy is going on. That means that all the universe is full of particles that are evolving towards a state which can be understood by the following example. If X be the state of a particle and X+1 is the state produced in it by any one of the million factors impacting that state then the future state of the particle is going to be more chaotic than X or X+1. Every new calculation made by the system for the future will grow more chaotic as the aberrant X will deviate more and more from its original position.

As mentioned in the Heisenberg principle the mere state of awareness/observation/entanglement changes the system being observed. So if a particular observation effects a system to grow more chaotic in the future then it is possible that the future state of affairs can be changed by a thought or a level of entanglement with the system.

I am sure the results that a person desires also have to be translatable in the language of life. Unfortunately life does not understand winning the lottery so no matter how much one can think or entangle or contemplate on winning the lottery it is not very liable to happen. The language of life will probably also not understand the language of money. But what it does understand is that if one wishes for happiness or if one wishes to find an answer about a question or if one wishes for fulfillment or enlightenment the whole universe conspires to bring that around. Usually materials or objects will be used to bring around the end result and the possibilities are endless how a particular wish is granted. The time of the fulfillment are also something that life chooses.

Heisenberg Uncertainty Principle

The more precisely the POSITION is determined,
the less precisely the MOMENTUM is known.

While this is a specific statement concerning two characteristics of a particle, there are many interpretations also which apply this principle to the observer and the observed. It can also be called the observer effect. It is used to describe changes that the act of observing will make on the phenomenon being observed. In psychology it refers to the behavior of anyone being observed changing by the act of the observation.

Position and momentum are two characteristics of a particle that are being used to study it. If we consider the particle to be an analogy of life, then the two characteristics that we can use to study life are through the mind or through the heart (thoughts or feelings).

Neurobiologically both heart and mind are denizens of the brain and their interactions with each other are complex. At a certain level just like a particle can be described as pure momentum or pure mass (the dual theory of light) thus any perception of the mind can be accomplished using entirely reason or entirely feelings. That is a polarized level and in the interest of talking about averages we will consider the middle ground in the dyads of thought-feeling and momentum-mass. In the middle ground of the thought-feeling dyad, one cannot exist without the other. To separate the two probes of sensing is not possible. Primarily "thought" can be used to observe an object based on its height, length and depth but without the "feeling" the object being sensed will remain in a vacuum. The information about an apple will only be complete once I know that it is red and that it promises the same feeling as I had when I ate a similar one.A balance between thought and feeling needs to be struck for me to decide on the observation about that apple.

Human beings cannot be aware of the true state of affairs if they utilize feeling or reason alone. To be aware of the nearest estimate one has to use a blend of thought and feeling. Just like to determine the nature of particle ony postion or only momentum cannot be used. Both have to be used in conjunction and knowing at the same time what the possibility of error is.

We were talking about an apple which happens to be an object of mass. Hence to perceive it fully to ourselves in the two poles of thought and feeling, we might need to perceive it closer to the pole of thought. Similarly if we were attempting to perceive an aesthetic concept or art, it might be useful to perceive it closer to the pole of feeling. The truce that we negotiate in between the extent of thought and extent of feeling is intuition. Just like mathematical formulae can give the probability and extent of error in oberving particles, our souls or whatever the organ of intuition is called, determines the adequacy of our under or over reliance on thought and feeling.

So the question arises whether it is a good idea to observe life and reach a useful conclusion about it with reason or feeling. Is it good to think about life or is it good to believe in it without question. The great instrument of orientation is the thing by which we come up with an answer to this.

"Human beings are feeling animals", some say. Agreed that the primitive brain (amygdala, thatlamus, hypothalamus and pituitary) is entirely feeling. However the telencephalon or the executive brain is also well developed and both parts can override each other depending on the situation. If feeling is the only thing that is used to perceive life and make decisions about it, then we run the risk of turning into suicide bombers. If reason is the only thing that is used to perceive life and make decisions about it, then we run the risk of becoming an equally abhorrent creed of scientists.

A Dream Triptych about Gustafson

I have had the luck and the fortune to learn from Dr Gustafson. The following dream triptych I believe describes a journey which is defined by the first dream and ends with the last dream.

ACT I:


As a part of residency training in our program we were required to have one hour per week of general psychiatry supervision and one hour per week of psychotherapy supervision. In the third year I had requested Dr Gustafson as a supervisor. The following dream marked that time.















Dream notes:
The dream is set in Silent Hill universe. It was in the film adaptation of silent hill. It was primarily focused on the siren which signaled the transition into the alternate universe. Dr Gustason had started recently writing his book The Great Instrument of Orientation.

Dream:
Throughout the dream, I was exploring a very strange house. I had the feeling constantly that we had to get out before the universe changed into the dark one. With me was Dr Gustafson and there was the siren which scared me and gave a desperate longing and spurred a frantic struggle to get out of the house. My guide was Dr Gustafson and together through various rooms we made our way. We had pistols and we killed several monsters in the process of trying to fight our way out.

Interpretation:
Dealing with psychiatric patients is a tricky business.

ACT II:






Dream notes:
This dream was set in the painting of the last supper. Instead of JC I had a condensed figure in it. By this time I was roughly half way through the supervision with Dr Gustafson. I had already seen him transform his everyday life encounters into words and pen them down. The rigorous discipline which came to him like breathing (inspiration and expiration). I had by this time asked myself the big question of why life was going in and out of silent hill psychosis.
Also of note all pulmonologic diseases are divided into those dealing with inspiration(restrictive) and those deal with expiration(obstructive)
(Thanks to Darkdiscordia)



Dream:
The main figure was that of Jesus who was not Jesus but a condensed figure that I had created by combining a Pulmonology attending that I once met and Dr Gustafson. The Pulmonology attending I described next day to Dr Gustafson as "a show off who was very capable but liked showing off to his students". I was asking the savior about a Pulmonologic illness that I was suffering from and the condensed figure of the savior looked at me and said to me, "the problem with you is not in the expiration but in the inspiration."

Interpretation:
Inspiration can be difficult when the organism is threatened with expiration at every instance.


ACT III:



Dream notes:
The third and the last of the Triptych, I had the night that I received news that Dr Gustafson had published his book. All through the dream instead of seeing that book, I was thinking about Eckhart Tolle and A New Earth.

Dream:
I was going around a table of people who were studiously writing about something. Each had their own book and I was going around trying to make out the book that each person had with them. Suddenly I stopped because I saw a new book by Eckhart Tolle. I knew he had not written a new book after A New Earth. Not wanting to interrupt the person who was working with this new book, I took great pains to glance at the cover about this new book.

Interpretation:
Dr Gustafson writes about the dream "The dream could be taken several different ways, of course: one is that the new author is yourself, which seems to be exciting in finding your own center; another that you are getting pulled into someone else's center."

VACTERL association

V- Vertebral anomalies
A- Anal Atresia
C- Cardiovascular anomalies
T- Tracheoesophageal fistula
E-Esophagial Atresia
R- Renal anomalies or Radial anomalies
L- Limb anomalies

This is an association not a syndrome because of a lack of one single pathogenic gene. PubMed as of 9/15/08 does not give any psychological sequelae to this association. That is odd, given the neuroectodermal involvement as evidenced by the vertebral anomalies.
One paper found that IQ did not tend to be different from any other children hence the need to address individual anomalies early on is essential. Like any other chronic disease the earlier any barriers to development are removed the more "normal" the development.
Here is a network for family and children with VACTERL .
I have seen one child with this syndrome with anger issues. I did not have the opportunity to engage in a psychiatric interview though so I cannot delineate the etiology of the anger.

More research needed. :)

All the rivers of psychodynamic therapy combine

I hold to the belief of all therapy having one common theme to it. There is one expectation from therapy and that is too work. And sometimes not to work but do the least bit of damage. To explain all the intricate manifestation of human behavior, all theories come fairly close to each other. Yes they differ also on some key elements but then again if a therapist cannot practice being all inclusive, he or she runs the danger of trying to see everything in the world as all squares or as all circles.
The discussion of Beck about modes of cognition which exist in our minds and how they become activated through cognitive reactivity brings back some memories of archetypes that Jung talks about.
My psychotherapy supervisor, who i just started with believes in thinking in psycho dynamic terms but making plans keeping in mind behavioral or interpersonal principles. I found his approach as somewhat unique. He believes that initially the problem needs to clarified. One should be clear whether one is dealing with problem of libidinal drives, problem of function of the ego (like reality testing, impulse control etc), problem with how the person perceives the world around it or how the person recognizes itself. By this he is combining all the schools of psycho dynamics and giving each of them a place to help formulate each case.
The four schools broadly being drive theory, self psychology, object relations and ego psychology.

I think every good therapist tries to unite all these things in the mind and clinical practice. It is informative trying to see what every one's picture of unity looks like.

My previous psychotherapy supervisor who is a man held in awe by many including myself, was a minimalist. He was the king of brevity. Actually still is. He saw all therapy and condensed it into the very basic rudimentary dynamic. On those basic framework of dynamics he would plan the clinical dance to take some very interesting forms.

Pakistan and ADHD

I was trying to research ADHD in Pakistan today and came across this article from J Pak Med Assoc. 2003 Sep;53(9):441-3

Qureshi A, Thaver D.Aga Khan University Hospital, Karachi.

Ok so ADHD exists in Pakistan. Now what is the treatment for it. Primarily would be the use of analeptics. If one class of analeptics is not effective the medication can be switched to the other class and ~90% children respond. One class being the Methylphenidate products like Ritalin and the long acting methylphenidate products and methylated compounds of methylphenidate. The other class is the amphetamine salts like dextroamphetamine and the mixture of the two enantiomers of the dextroamphetamine (Adderall, Vyvanse, Dexedrine). In Pakistan only the MPH compounds are available.

I found Ritalin at an online pharmacy. 10 mg tablets. The price is Rs 4.7 for 10mg. It is certainly not steep. A 40kg child would be taking roughly 1mg/kg/dose as the high end would end up spending ~Rs 18. If this dose is taken two to three times a day the cost increases up to 18x3=54. If this is not given on days off from school, the child will take it ~20 days. So Rs 1080 for an entire month.

Now the question is what is the other option besides Ritalin. Nothing. I have not been able to find Amphetamine salts. Second line medications like Alpha 2 agonists (Guanfacine and Clonidine) which are also used as blood pressure medications are also not available.

Bupropion is available. This also a second to third line agent. 75 mg tablet costs Rs 10. It is usually needed in doses of 150mg-300mg and everyday medication will make it a cost of anywhere from Rs 600-Rs 1200 per month.

Atomoxetine is not available. That would also be a second to third line agent. Especially useful in children who cannot withstand analeptics.

Then there is the tricyclics, which are available but that would be third line agents and not the best medications for a hyperactive child. Side effect profile unfavorable.

Iphone and Netter

Netter has made some excellent products available. Initially there was the Anatomy flash cards.
Here is the video from the key note speech.
Since then another very nifty little app that has come for the iphone is the Netter's neuroscience flash cards. Check them out in itunes.
Their is functionality to zoom which might be native to the OS. This is an ideal tool for psychiatrists who are preparing for boards and for eager enthusiasts who are studying neuroscience. You correlate it with the picture and the function is difficult to forget. Ofcourse $40 is a little pricey. Residents get the book money ready.