Anger displacement during Social Isolation

-“Doctor…when I arrive home, I can’t help lashing out at the kids—feel so guilty.”

Verschiebung. This German term can be translated as “Shift” or “move.” It was used by Sigmund Freud to describe a particular psychological defense mechanism; it entails the shifting or displacement of an aggressive and potentially dangerous emotion from an important person or object into other ones that are less relevant and often lame. [i] Our patient had many situations of emotional frustration in her blue- collar job with her despotic boss and his unreasonable demands at work but she hid her anger towards him and the system, fearful of losing her job in tough  times. On many occasions, she scolded her children a little bit too much for not completing their homework or for just some obnoxious but inconsequential pranks.

This unconscious defense mechanism is an expression of what Freud had dubbed as the mortido—our basic aggressive drive. There are three basic mechanisms:

  1. Displacement of object
  2. Displacement of attribution
  3. Bodily displacements

A – Displacement of object

Some acrid emotions are displaced from one person into another one. Our patient’s anger toward her boss—who has authority and power to decide on her economic survival—had indeed been transferred into her  children—who are totally innocent and incapable of posing a threat to her as they are dependent on her. This situation will sadly become much more common in our modern societies because the SARS-CoV-2 pandemic has furloughed millions of workers worldwide and many of them will not be able to return to their old jobs due to inevitable closure of businesses. In the much more genteel days of Freud’s practice in nineteenth century Vienna, he put the example of children’s animal phobias; in order “to sanitize” their fears towards their parents, some children develop aversion to certain animals: dogs, cats, spiders.

B – Displacement of attribution

A personality trait that we might see in ourselves but that we consider as socially unacceptable or even reprehensible will be transferred to another person or entity. The typical example is a closeted homosexual who engages in continuous joking about gays or other LGBTQ individuals to perform a psychological projection. We can also find extreme examples in History like the horrific persecution of gays in Nazi Germany conducted by Ernst Röhm, co-founder with Adolf Hitler of the Sturmabteilung (SA); he was a barely disguised homosexual that was executed in the middle of an orgy by the German Army—fearful that his formations were gaining too much strength in the street—during the Night of the Long Knives in 1934. [ii]

C – Bodily Displacements

It consists of the attribution of a sensation experienced by one part of the body to another distant one; one of the commonest instances is when an oral sensation “is experienced” as coming from the vagina. John Cleland wrote a book in 1748 titled Fanny Hill or Memoirs of a Woman of Pleasure [iii]where he used funny euphemisms in order to refer to body parts that were not openly mentioned in prudish Albion; he dubbed the vagina as the nethermouth. He was a rebellious writer and some sources claimed that he finished it when he was serving a prison sentence for a bad debt. He printed it in two installments in November 1748 and February 1749; he was released from prison in March 1748 (he graduated from the University of Life…I like him)

“I picked two fights at work. One with a customer and one in a Slack [iv] queue with my colleagues, and I regret both terribly. They are possibly the first two fights I have ever instigated in my life. Wish I could have hashtagged those. #furstfightbearwithme.”

Ms. Chrissie, a lovely, clever, funny fellow writer and blogger [v], honestly shared her unfortunate event in a recent blog, which triggered this reaction from yours truly:

“The little anger that you inadvertently vented against two individuals is part of the humongous one building up in the street. It happened to almost all of us lately.

Unfortunately as we slowly come out of our forced Social Distancing and we interact more with our fellow human beings, we will discover that not only they, but us as well, are displaying a shorter fuse and we might snap at the slightest incident. We might be able to contain ourselves outside our homes, with an occasional “mea culpa” if we allow our emotions to get the best of ourselves in the survival frenzy.  What we have to keep clearly in mind that we cannot—absolutely cannot—bring that heightened state of alertness and potential aggressiveness to our dear families. Maybe we should go back to the old ways from our ancestors to vent off that stress.

Get the punching bag from the attic. Paste the image of your boss right up. 

Go. And do not pull any punches. Sweet.

(This article was based on our upcoming new book Emotional Frustration- the hushed plague)

References

[i] Sigmund Freud, New Introductory letters on Psychoanalysis, George Allen and Unwin, London, January 1940,

[ii] https://en.wikipedia.org/wiki/Ernst-Rohm.

[iii] John Cleland, Fanny Hill, Gray Rabbit Publishing, London, 2018.

[iv] Chrissie described this tool as a fast-paced messenger service that is commonly used in certain offices. https://slack.com/

[v]  https://chrissie.blog/2020/05/13/are-you-okay/

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Multi-system inflammatory disease in Covid-19 infected children

On April 27, 2020, The Sun, a British newspaper with an American edition, published an article about a National Health Service warning about a new presentation of the Covid-19 infection in children; it even had flashy pictures of the new syndrome. The alert was sent to general practitioners in North London where the chiefs of health care delivery said: “there is growing concern that a Covid-19 related inflammatory syndrome is emerging in children in the UK…Over the last three weeks, there has been an apparent rise in the number of children of all ages presenting with a multi-system inflammatory state requiring intensive care across London and also in other regions of the UK.”

On April 27, 2020, the Pediatric Intensive Care Society of the United Kingdom issued a statement warning health care providers and parents that there was “an increased number of novel presentations of a multi-system inflammatory disease in critically ill children infected with Covid-19.” They recommended parents to seek proper professional help if their children had any of the following symptoms:

  1. Becomes pale, mottled and feels abnormally cold to the touch
  2. Has pauses in their breathing (apneas), has an irregular breathing pattern or starts grunting
  3. Severe difficulty in breathing, becoming agitated or unresponsive
  4. Is going blue round the lips
  5. Has a fit/seizure
  6. Becomes extremely distressed (crying inconsolably despite distraction), confused, very lethargic (difficult to wake) or unresponsive
  7. Develops a rash that does not disappear with pressure (the Glass test)
  8. Has testicular pain, especially in teenage boys

On May 4, 20220, the New York City Department of Health issued its Health Alert #13 stating that 15 children in New York City hospitals have been identified with a multi-system inflammatory syndrome that resembles Kawasaki disease and/or toxic shock syndrome. The NYC experts said that: “clinical features vary, depending on the affected organ system, but have been noted to include features of Kawasaki disease or features of shock; however, the full spectrum of disease is not yet known. Persistent fever and elevated inflammatory markers (CRP, troponin, etc.) have been seen among affected patients. Patients with this syndrome who have been admitted to pediatric intensive care units (PICUs) have required cardiac and/or respiratory support. Only severe cases may have been recognized at this time.”

On May 9, 2020, Governor Andrew M. Cuomo of New York informed in his daily update that three children had died of this multi-inflammatory syndrome in the New York area hospitals. Moreover, they had already identified up to 75 children with the syndrome. They were initially admitted without any respiratory symptoms but they all tested positive either for the virus or its antibodies. He warned that it is a developing serious situation.

Sadly, the emergence of this Kawasaki-like syndrome might just be the tip of the iceberg.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

 

Are Singles better prepared for Social Isolation?

The quasi-centennial woman had been living in the same humble shack with a loyal dog and a dozen chickens in a small clearing of one of the most forbidding sub-tropical forests of South America—El Impenetrable, a large expanse bordering the Bermejo River in the northwestern part of Chaco province and the southwestern part of Formosa provinces of Argentina. One of her many grandchildren, and sometimes even a great grandchild, would come to check on her and bring supplies almost daily but they all preferred to live in a nearby small urban settlement.

She claimed that her social isolation in such natural habitat suited her just fine. She woke up early every day to do her homely errands with enthusiasm, preparing her own meals based on a largely vegetarian diet with some poultry or freshwater fish. She continued to smoke moderately, and she sometimes drank a little alcohol too. When the reporter asked her what the secret of her unusual longevity was, she said:

“Because I don’t have a man that heats up my head every day.”

The forced social distancing and isolation brought by the Coronavirus pandemic has forcibly obliged millions of people to stop working in public/ private institutions or attending educational institutions with a resulting estrangement from other persons. Individuals with stable sex partnerships have been traditionally considered as more apt to withstand the Mental Health consequences of this kind of social situation. However, the previous existence of millions of men and women who had expressly chosen a single lifestyle in modern societies has gravely questioned that assumption.

In an article of the Health section of The Washington Post, Joan DelFattore reviewed the responses from several singles contacted by e-mail or found in the social media. “This is the moment I’ve been training for all my life!’ an unnamed introvert asserts in a Facebook post…Edie Jarolim, a freelance writer and editor in Arizona, can relate to that sentiment—that adults who have chosen to live alone may be better adapted than many to the stay-at-home restrictions in place in large parts of the USA.” Most of the respondents were nonetheless concerned that they could be discriminated against if rationing of the scarce health care resources—lifesaving ventilators for example—were eventually instituted in a dramatic junction of this terrible pandemic.

A longstanding complaint of the singlehood-by-choice surfaced again: the lack of respect for their lifestyle choice from the mainstream citizenry. Many persons confound the fact of “being alone” with the sentiment of “being lonely.” Especially because they disregard that many of these singles do have a strong social support. Moreover, the lack of sentimental strings prods them to seek a varied company.

Since Biblical times, humans have been strongly encouraged to socialize and live in partnership with the opposite sex for healthier social outcomes. There has been a large pool of scientific literature to buttress the need for a stable sexual partner to avoid anxiety/depression, insomnia, obesity, cardiovascular disturbances, etc. But how about those individuals that expressly chose the singlehood to be more creative?

Julie C. Bowker, Miriam T. Stotsky and Rebecca G. Ekin published a seminal paper in 2017 where they examined the links between the withdrawal subtypes and some psycho-behavioral variables, finding challenging results for the avoidance models of withdrawal; they found that unsociability is associated positively with creativity. Julie Bowker said: “they are not antisocial…they don’t initiate interaction, but also don’t appear to turn down invitations from peers. Therefore they may get just enough peer interaction so that when they are alone, they are able to enjoy that solitude.” In order to study these unsociable-by-choice from the truly shy individuals or those who exhibit abnormal anti-social attitudes, they recruited 295 college students and subjected them to a battery of psychological testing. They found that those who were in fact shy or antisocial scored lower than average on the creativity indicators; the participants who were “unsociable” scored higher on those same indicators.

These authors proposed that unsociable persons “may be able to spend their time in solitude constructively, unlike shy and avoidant individuals who may be too distracted and/or preoccupied by their negative cognitions and distress.”

A question that has lingered in our mind for many years might merit to come into the open on this occasion. Like most human beings, we have commiserated with the miserable and lonely life that Vincent Van Gogh endured until the very last instant of his tortured life. However, would he have been able to produce so many beautiful tableaux of so many simple situations if he had been a most happily married man?

Stay distant. Stay safe. Stay beautiful.

(This article is based on our upcoming new book Emotional Frustration – the hushed palgue)

What do you think? Please tell us.

Don’t leave me alone.

 

 

 

 

How to survive a brutal Social Isolation

A few days ago we attended a webinar given by a supposedly academic expert in Mental Health on the psychological consequences of forced social isolation. After an initial good exposure of expected consequences of loneliness and isolation in human beings, the presenter started to wallow in a sea of unbelievably banal platitudes, which were tagged by a cohort of naive attendees asking inconsequential questions. Right away we knew that she did not a have a clue about the effects of this kind of brutally enforced isolation.

For all the countless diplomas held by both the speaker and the attendees, they were evidently lacking the most important one to guarantee the expertise for this subject. Not a single one of them attended the tough course work of the University of Life. Not a single one of them was summarily given a crash course on isolation: jailtime.

In the seventies, the brutal military dictatorships of Uruguay and Argentina (where we were studying our medical career at the time) did not have any efficient methods to verify the identity and criminal records of anyone they stopped in the street during their frequent fascist “razzias” [i] to detect the presence of leftist political activists. When the officer in charge of the platoon decided that you could be a suspect, you had to silently comply with the arrest order and ended up in a police station, waiting for their request for records to go through the official channels. Without any protest.

In one of those “passes”, an ageing pickpocket who was a regular of that jail told us:

-“Listen, young man…I don’t know how long they are going to keep you here. Most likely just a few days and then they’ll let you go. But, just in case, you have to learn and use the two basic principles of survival in jail. It’s mandatory here—”

-“Oh, yeah,” we replied with a touch of sarcasm. “What are they?”

-“The first one is to always keep track of time, with any possible means. If you do not have any idea of what day of the week and what hour of the day you are living, you will progressively deteriorate…Seen too many guys like you going downhill.”

-“And the other one?”

-“Follow the leaders’ instructions and respect the discipline inside a jail…It’s the only way to survive without any lasting mental or physical consequences…Got it?”

-“Yeah…I guess so…”

-“Good. Grab this,” he said, handing us a broom.” “Last arrival, sweeps the floor.”

The two basic survival techniques in a situation of extreme forced isolation are:

  1. Safeguard your circadian rhythm at all times
  2. Adhere to a strict discipline of basic social and personal tasks

A – Safeguard your circadian rhythm at all times

An extreme situation of forced isolation from the rest of society will bring extreme anxiety and ultimately depression to any but trained soldiers or hardened criminals. One of the first things that happens is that, almost immobilized in a very limited space where the normal parameters of life vanish, you start losing the sense of Time. Slowly you lose track of the hours or the period of the day; if you spend more than a few days of seclusion in a closed space, you will start losing the sense of Seasons.

The multiple sensorial stimuli that our body receptors catch during a normal day will suddenly disappear or at least significantly diminish during a forced isolation. We will no longer feel the blinding effect of the early dawn Sun coming from the East. We will no longer smell the enticing aroma of a delicious dish signaling it is noon. We will no longer see the sudden rush of people in the street marking rush hour time.

Like a mechanical grandfatherly clock that, in spite of all its majestic presence, needs the regular clanking of a little winding knob in the back to keep working, our internal biological clock needs those stimuli to regulate our bodily functions properly. We all have our routine eating, grooming and sleeping schedules that suit our needs. When you are in jail, you might spend too much time sleeping or lounging in bed. Not in a mood to appreciate the little pleasures of life, you start to skip many meals. Resentful of your sort and disdain courtesy for others, you use the bathroom at will.

The first order of the day should be to wake up at a reasonable time during daytime; if you are used to working or studying at night, then you can revert the directive. The second order of the day should be to fill your day with meaningful tasks that are useful for yourself and the individuals that are sharing the compulsory confinement. The third order of the day is to always find a glimmer of sunshine or outside light. Even with a minor stimulus of the temperature and vision receptors, our hormonal system (with the Hypophysis directing the responses) will better regulate our bodily functions.

One of the most annoying side effects of this isolation is an unrelenting constipation. You must sit down at the toilet regularly, even though you might not feel the need. If the organic waste materials, which will continue to be produced even with a more meager amount of food intake, keep accumulating in our bodies, they will poison us.

B – Strict discipline for basic Personal ad Social tasks

One of the most disseminated misconceptions in popular lore is that prisons are a place of constant chaos, of unbridled lawlessness, of unchecked release of passion. On the contrary. The best run prisons are steered with a firm hand accepted by all. The only way to have a semblance of functionality with so many people with different interests in such a limited space is to prod everybody—prisoners, guards and administrative cadres—to respect the basic rules of a peaceful co-existence.

When one of your companions with a higher hierarchical role in your organization is also confined with you, you will naturally follow the informal power structure. One of the more memorable film scenes happens when the British Army survivors of the Fall of Singapore[ii], after a tough trek through malaria-infested territory , march in formation into the prisoners’ jungle camp, led by a solemn Alec Guinness playing their top officer, whistling the tune of The bridge in the River Kwai.[iii] Simply Stupendous.

First of all , you must respect the general guidelines, which in our case are enforced by the police and first-responders’ personnel who are bravely exposing themselves in the line of duty. Then come the particular guidelines of where you reside, which are related to the basic sanitary and safety measures of buildings, apartments, neighborhoods, etc. Finally you have to consider the personal guidelines for all those living under the same roof, i.e. your parents, your spouse, your children, your guests, your personnel, etc.

If you only have one bathroom, you cannot spend an hour singing in the shower. If there is a communal sharing of the kitchen, you must always clean up after yourself. If there is a pet in the house, you must take turns to clean it, to exercise it, etc. If there are children, you must consider their critical need for distraction with games, TV, etc. If you like to smoke, you must go out in the patio to avoid the secondary smoking damage to others. If you like to listen to music, you must lower the volume, especially at nighttime.

If you follow all the basic rules of co-existence, you will have the peace of mind to sit down in a comfortable setting to then read, study, write, work at a distance, etc. The methodical practice of studying and writing at home for many years already has prepared us to rather smoothly transition our lifestyle into this forced social isolation. Our son Gian Luca, a student at Florida State University, is sharing this ordeal with us and we are carrying our professional and academic tasks with a certain panache.

Gian Luca just told us that Stanley Kubrick, the famous cinematographer that loved Vincent van Gogh’s  paintings, used the remembrance of the tableau that serves as our featured image to design a scene in A Clockwork’s Orange where the inmates of a juvenile detention  center walk around in a small circle of the prison yard, surrounded by tall brick walls  and under the attentive eye of the armed guard. Moreover in another one of his films, one of the lead characters offered a book about van Gogh as a gift. Even though we did see the film many, many  years ago, we could not remember that scene. But the keen filmmaker’s eye of Gian Luca has stored thousands of images in his brain. The close interaction with our dear son in this forced isolation. A little heavenly perk.

A clockwork orange

As François Macron, the President of France, just said addressing the French Nation:

On doit se réinventer, moi le premier [iv]

Stay distant. Stay safe. Stay beautiful.

(This article is based in our upcoming new book Emotional Frustration – the hushed plague)

What do you think ? Please tell us.

Don’t leave me alone.

References                                    

[i] Term in Italian that refers to the sweeping incursions of the police and military in their enemy’s territory, searching for opposition activists. The military dictatorships considered the civilian population of both countries largely as “their enemies.”

[ii] In the beginning of World War II, the British Army considered that their bastion of Singapore could not fall to the Japanese Army as high caliber artillery was arraigned against the sea entrance lanes and the British Navy patrolled them round the clock. But the Japanese marched down through Malaysia and swiftly approached the city from behind, where it was less powerfully defended.

[iii] https://imdb.com/title/tt0050212/

[iv] Sentence taken from President François Macron’s address to the French nation we listened through Radio France Inter on April 13, 2020.

Masturbation during Social Isolation – Part I

The enforced social isolation during the pandemic for millions of people around the globe will exacerbate certain personal and community tensions that have been latent for many decades. One of them is the issue of Onanism which, in spite of being as old as Mankind itself, has taken a new twist due to the cloistering of so many single persons without the possibility of going out to meet a partner. In order to start the much needed and long postponed discussion, we will first transcribe what we already wrote about this issue in our upcoming book “Emotional Frustration – the hushed plague”

-“Doctor…Before serving a dish to a customer, got to try it myself.”

Tanya X. is the feisty, lesbian sous-chef of a posh beach resto that jokingly told us that, despite having a partner, she used “self-stimulation” as an appetizer. There is a high prevalence of masturbation in the USA[i], both amongst the young and adult persons, but it is still considered as a taboo issue in most public forums. Despite a strong social opposition, that practice is slowly “coming out.”

The National Health and Social Life Survey, administered by the University of Chicago, showed that in the 18-60 years old segment, 38% of women and 61% of men said that they had at least one episode the previous year. The masturbation-partnered sex linkage had a bimodal presentation for both genders as it was both a compensation for an unsatisfying sex life and an addition to a satisfying one too.

Yvonne Fulbright, a relationship expert and writer, said: “how to stimulate the ‘hot spots’, whether your own or your lover’s, can be a piece of cake—that is once you know the recipe. The secret to becoming a rave-inspiring ‘masterchef’ in the bedroom is knowing when (and how) to throw in a dash of this or a pinch of that, let the things simmer a bit or even mix up the ingredients. It’s also important to know why the right blend makes things so sweet.” [ii] A personalized cookbook.

Researchers at the Kinsey Institute [iii] interviewed more than a thousand heterosexual Australians about what they usually hide below the bedsheets. The data showed that only 61.6% of women claimed to reach an orgasm during sexual intercourse compared to almost 85.5% of men that claimed they did. Almost 38% of the participating women said that they needed stimulation of the clitoris to reach an orgasm in 75% of the sexual encounters they had had; the investigators  stated that previous clinical studies did not fully address the issue of clitoral stimulation.

Stay distant. Stay safe. Stay beautiful.

(This article is based on our upcoming new book Emotional Frustration – the hushed plague)

What do you think? Please tell us.

Don’t leave me alone.

References

[i] Das A.“Masturbation in the United States”, Journal of Sex and Marital Therapy 2007 Jul-Sep:33(4)301-17.

https://www.ncbi.nlm.nih.gov/pubmed/17541849

[ii] Yvonne K. Fulbright, “Touch me there. A hands-on Guide to your Orgasmic Hot Spots”, Hunter House, Kindle edition. https://hunterhouse.com

[iii] https://kinseyinstitute.org/pdf/womens%20orgasm%20annual%20review.pdf 

Data Science in Medicine – Part I

Only a few years ago Health Care practitioners would methodically write down their clinical impressions during a face to face interview with patients and then pass the chart to a waiting nurse or aide that would proceed to the next stage. The piece of paper was the final trustworthy depositary for all the clinicians’ opinions and recommendations. Then the chart would eventually be shared with other professionals, technicians, administrators, payors’ functionaries, etc., and ultimately find its home in an archive.

The advent of Electronic Record-keeping has dramatically upended that quaint era and changed all the paradigms of care delivery for all the involved parties. As most practitioners sit in front of their terminals and type along the patients’ narrative, once the face to face clinical encounters are finished and the patients leave the medical office, a torrent of medical information also rushes out of the door with them too. Then it proceeds to feed several endpoints related to consulting offices, studies’ referrals, control and audit, pharmacies’ inboxes, administrative oversight, etc.

We are living in an era when every time we click on our computers or smartphones, every time we send any messages, every time we manifest any preferences in the social media, there is a quick sharing of information that escapes our control and becomes manipulated by total strangers as we have described in a previous article. However, this technological tsunami can become very useful for the smart medical researchers who can analyze and interpret  humongous amounts of data sets. Using ever changing algorithms and powerful computers, they can mine gold from it.

The classical tenets of medical research are changing dramatically as breakthroughs are achieved by biomedical researchers, mathematicians, computer programmers, statisticians and several others that contribute specific skills for the task at hand; together they can “read” from the enormous amount of data to find significant correlations between seemingly disconnected facts to swiftly inform practitioners. The biggest gains from Data Science have occurred in the field of genomics, thus enabling to tailor treatments to the patients’ unique characteristics in Oncology, Hematology, Cardiovascular diseases, Neurological diseases, Ophtalmological disorders, etc.

At present the first priority of the research community is to figure out multiple ways to share clinical, laboratory and technical data in real-time with their peers all over the country and beyond in order to use it to find innovative, revolutionary cures. The Observational Health Data Sciences Informatics program (OHDSI) has designed a data- sharing network of medical investigators of multiple institutions in twenty-five countries to study the medical records of almost 400 million (yes, million) people. The Department of Biomedical Informatics at the Columbia University Irving Medical Center (CUIMC) has the responsibility of coordinating this research; they are already actively mining the data and producing outstanding results in racial disparities of health care access and equity, cross-national differences, hidden side effects of drugs, etc. We will discuss many of them in future installments of our next blogging season.

What do you think? Please tell us.

Don’t leave me alone.

Artificial Intelligence (AI) in Medicine –part I

There are some things or issues that we eagerly discuss in the public forum with the certainty that it dramatically concerns us all and should be addressed forthrightly. While we waste time in endless intellectual discussions about their different aspects, that thing or issue is silently seeping through into the own fabric of our societies. We have the illusory comfort that our civic concerns might modify and/ or mollify their progress. Those fetishist vagaries give them the time to invade our personal spaces and seize our lives. The use of Artificial Intelligence (AI) is a case in point. It is already here with us.

Awake or asleep, we are already sharing a significant part of our lives with various machines that process humongous loads of data to deliver specific, tailored services for us all. When we join a chat or dating group, when we load up pictures in our platforms, when we program appliances in our techie-laden homes, when we plan a vacation, etc., we provide a lot of information to computers and programs that efficiently process it. The arrival of AI in the medical realm has been fostered by the need to process vast amounts of data for precise diagnoses and treatment protocols to get good outcomes.

In an April 2019 position paper, Dr. Scott Gottlieb, the outgoing director of the Food and Drug Administration (FDA), designed the basis for the regulatory framework to authorize and supervise the medical devices infused with the Artificial Intelligence. Dr. Gottlieb emphasized that there was a critical need to build guardrails to protect the development of new techniques and algorithms without stifling the innovation or restricting the access to breakthrough treatments for patients in critical need. He said that: “Artificial Intelligence and machine learning have the potential to fundamentally transform the delivery of health care…As technology and science advance, we can expect to see earlier disease detection, more accurate diagnosis, more targeted therapies, and significant improvements in personalized medicine.”

In the past, the FDA has been acerbically criticized by scientist, physicians, patients and almost all the professional cadres of the Health Care realm because of its slow, step-by-step review of any major technology, drug or treatment to assure the efficacy and safety of any new product that aspires to swiftly enter the commercial market. Acknowledging that its traditional approach is unfit for rapidly evolving treatment algorithms that are constantly being updated using the field data, the FDA is devising novel ways to allow the software to evolve and adapt to changing circumstances while at the same time steadily meeting the stringent safety requirements of the institutional regulator.

We celebrated our birthday with our son by sharing a nice dinner and a night out at the movies. What film did we see? Terminator Dark Fate, of course. It won’t be long before any of you us would be relaxing at the operating table with the early effects of a total anesthesia when we will suddenly notice a familiar figure approaching us in green scrubs:

-“Hi, my name is Dr. Arnold,” he would say with a hoarse Teutonic accent. “I will be performing your surgery today. Any questions?” Let us confess that his mechanically smiling face will not appear as that re-assuring to us in that moment.

What do you think? Please tell us.

Don’t leave me alone.

Love and Libido after a Total Mastectomy

Women have a strong sense of self and body that helps them visualize themselves at all times. A small physical defect will hardly ever pass unnoticed and unacknowledged by the dear women. In a mirror image, they will perceive “what the other sees” in her, especially the other women. Then it should come as no surprise that the utterly traumatic surgical event of a Total Mastectomy for Breast Cancer often has a devastating physical and psychological tally on their minds and moods.  In order to experience libido or “the desire for sexual company”, women have to feel at ease from the physical and emotional standpoints, which is hardly the case in post-surgical patients. This is one of the least discussed issues in our medical practices, compounded by the fact that it is almost never addressed in medical schools’ curriculums, even in the supposedly “enlightened” countries. Physicians and other health care personnel are left with the extremely bad option of learning sur-le-champ, often quasi-alone.

After forty years of medical practice, we have collected a few nuggets of wisdom for these patients, even though we never practiced Gynecology and we have always avoided doing any Gyn exams ever since we were in medical school. However, talking to patients and friends after undergoing that procedure, we found these challenging issues:

  1. Toxicity of associated medication.
  2. The unwise hurry to have a Prosthesis.
  3. The lack of an honest discussion between partners
  4. The absence of a proper bereavement process

A – Toxicity of associated medication

In 1998 the Food and Drug Administration (FDA) approved the use of Tamoxifen for the use in both men and women that were diagnosed with hormone-receptor-positive early-stage Breast Cancer to avoid the recurrence of the disease after surgery; similarly it is being used for patients with advanced-stage of the disease and had metastases of a hormone-receptor-positive neoplasia. The pharmacological activity is dependent on its conversion to its active metabolite, endoxifen, by the enzyme CYP2D6, which acts as an estrogen modulator to competitively inhibit the binding of endogenous estrogens. It is available in a pill form (Nolvadex) or  a liquid from, easier to swallow (Soltamox) Almost ten percent of Breast Cancer patients have a slow-functioning CYP2D6, which can hamper the effectiveness of the drug and several medications, most notably the selective serotonin re-uptake inhibitors (SSRIs) like the anti-depressants, can block its activity. This drug has serious side effects like blood clots, Stroke and Endometrial Cancer but also less prominent ones like vaginal bleeding, dryness of vagina and loss of libido that affect the quality of life.

B – The unwise hurry to have a Prosthesis

Many surgeons precipitously offer the possibility of having a prosthesis installed right after the resection, in a kind of “two-for-one” deal to supposedly expedite the healing process of women. Unfortunately, most women would surely miss “the part that was taken away” and consider that prosthesis as an alien object that does not have the necessary seal of approval by her hormonal and psychological self. If there was an honest discussion with her family and sexual partner about the traumatic aftermath of the procedure, why rush through the protocols and insert the prosthesis?

C – The lack of an honest discussion between partners

There is not a hint of sexual enticement or libidinal drive in a woman that feels nausea and pain after the surgical act, compounded by the psychological stigma of “being uglier’ than before. Patients have to take charge of the physical and emotional distress to slowly research and find the pharmacological, hormonal, psychological and sociological interventions to ease her burden. One of the most damaging approaches consist of “sticking the head in the ground’ like an ostrich to avoid facing the dark undertones of this radical procedure. Nothing will be the same after it. Patients, partners and family members must honestly deal with the reality and find ways to heal. Women should make clear to their partners that they cannot recover the same kind of sex life. There will be times of physical discomfort, depressive states, untoward side effects and frustration. The patient, partner and family should carefully consult the caring professionals to find the proper pharmacological solutions and psychological help to overcome the trauma post-mastectomy.

D – The absence of a proper bereavement process

When we lose a loved one, we must sadly go through one the worst human processes: bereavement. After the initial shock and denial stages, we progressively start accepting that most tragic fact. Only after we methodically go through each and every stage, will we be able to overcome grief. Similarly, a woman, that was aesthetically and psychologically attached to her own body before,  must go through the same stages until she can find a way (or ways) to cope with the stark reality. In those circumstances, the sustained support of her partner and family play a pivotal role.

After a Total Mastectomy, a savvy woman will learn the new parameters of her new physical and psychological coordinates and, eventually, she will recover her lost desire for sex and company. She will need the continued assistance, tolerance and patience of all those who love her dearly. Piercing through her dense fog of dire despair, we should be a beacon of hope and encouragement so she can resume her life journey in earnest.

What do you think? Please tell us.

Don’t leave me alone.

 

Epigenetics

(This article was adapted from our new book Emotional Frustration-the hushed plague.)

After the Darwinian revolutionary writings[i] enshrined the concept that natural selection and evolution were the major mechanisms to modify our bodies, some alternative hypotheses were summarily discarded for the sake of clarity. Jean Baptiste Lamarck, a French naturalist, proposed that all the species have strived to attain the perfect state, for which there are multiple variations; the living organisms not only evolved but they did it slowly, little by little and successively.[ii]

In 1800 Lamarck gave his first lecture in the prestigious Musée National d’ Histoire Naturelle where he discussed the mutability of species—later developed in a book.[iii] According to Lamarck, life becomes diversified due to these factors:

  1. The Power of Life: tends to make organizations increasingly complex.
  2. Effects of the Environment: modifying influence of circumstances.

When the molecular structure of the human DNA was discovered by Watson and Crick in 1953[iv], scientists determined that its coded information could not be altered in any significant way by the environment or the person’s lifestyle choices. In 1975 Robin Holliday and John Pugh, English biologists, and Arthur Riggs, an American, found that methylation—an inherited chemical change of the DNA strand—can be modified by the environmental factors.[v] Epigenetics.[vi]

Studying laboratory animals, they discovered that severe environmental stress can have long-term effects in the information provided by the genes, i.e. epigenesis. The genetic material stays untouched but its “expression” or “reading” is greatly altered; this biological alteration can be transmitted in some instances to future generations that have not experienced the initial triggering factor in their lifetimes. Rat or mouse pups are subjected to maternal separation and then their behavior is studied for signs of depression; their genetic material is analyzed for alterations.

Rudolph and Adrian Bird published a seminal paper in 2003 where they said: “stable alterations of this kind are ‘epigenetic’ because they are heritable in the short term but do not involve mutations of the DNA itself. Research over the past few years have focused on two molecular mechanisms that mediate epigenetic phenomena: DNA methylation and histones modifications.”[vii]  As part of our reaction to stress, we secrete a hormone called glucocorticoid that mediates certain immune mechanisms like inflammation; when the offending agent disappears, the glucocorticoids bind to some brain receptors and its production in the adrenal cortex stops in a feedback loop. [viii]In 2106 Gustavo Turecki and Michael Meaney published a paper where they show that the gene that codifies this glucocorticoid receptor is inactive in animals that had experienced great stress in their early days, thereby limiting their ability to shut off its production.[ix] Even after the cause for stress has disappeared, they keep producing the stress hormone.

The epigenetic mechanism consists of a physical barrier of methyl markers in the DNA, which prevents the proper reading of the stored information in genes. Can this epigenetic trait be transmitted from a mother to her children? Scientists are still debating this issue but there are indications that when the DNA replicates during the cell mitosis, the methyl markings can be introduced in the new genetic material.

Scientific studies have shown that when women are subjected to undue stress during pregnancy, they give birth to children with impaired responses to stress. After the Allied landing in Normandy in August 1944, there was a prolonged stand-off between the opposing armies in the Lower countries, Belgium and Holland.[x] In order to force the population into not helping the Resistance and the advancing armies of Montgomery and Patton, the German Army rationed food supplies.[xi] The women who were pregnant at the time of the tragic Dutch Hunger winter, eventually gave birth to children with a higher rate of obesity and schizophrenia.  Nadine Burke Harris says that the origin of many of our societal problems may arise from the exposure to undue stress in childhood that leave a genetic marking.[xii]

Did our mothers and grandmothers possess the right intuition before science confirmed it?

What do you think? Please tell us.

Don’t leave me alone.

References

[i] Charles Darwin, “On the origin of species”, Mass Market Paperback, New York, 2003.

https://www.amazon.com/Origin-Species-150th-Anniversary/dp/0451529065

[ii] Encyclopedia Britannica, “Jean-Baptiste Lamarck”, https://www.britannica.com/biography/Jean-Baptiste-Lamarck

[iii] Jean Baptiste de Monet de Lamarck, « Recherche sur l’organisation des corps vivants : précédé du discours d’ouverture du cours de zoologie donne dans le Musée d’Histoire Naturelle » Fayard, Paris, 1986.

https://www.amazon.com/Recherches-sur-lorganisation-corps-vivants/dp/2213017018

[iv] Leslie A. Pray, “Discovery of DNA structure and function: Watson and Crick” Nature Education, 1(1):100, 2008.

[v] Nelson Cabej, “Building the most complex structure on Earth: an epigenetic narrative of Development and Evolution of animals”, Elsevier, February 2013.

https://www.elsevier.com/books/building-the-most-complex-structure-on-earth/cabej/978-0-12-401667-5

[vi] Israel Rosenfield, Edward Ziff. “Epigenetics: The Evolution Revolution”, The New York Review of Books, June 7, 2018. https://www.nybooks.com/articles/2018/06/07/epigenetics-the-evolution-revolution/

[vii] Jaenisch R., Bird A., “Epigenetic regulation of gene expression: how the genome integrates intrinsic and environmental signals” Natural Genetics, 2003 March, Supplement 245-54.1

https://www.ncbi.nlm.nih.gov/pubmed/12610534

[viii] Robert M. Sapolsky, L. Michael Romero, Allan U. Munck, “How do Glucocorticoids Influence Stress responses? Integrating Permissive, Suppressive, Stimulatory, and Preparative Actions” Endocrine Reviews, Volume 21, Issue 1, February 2000, pages 55-89. https://doi.org/10.1210/edrv.21.1.0389

[ix] https://www.utsc.utoronto.ca/~pmcgowan/documents/McGowanBrainRes08.pdf

[x] William Shirer, “The rise and fall of the Third Reich, Fiftieth Anniversary edition”, Barnes and Noble, 2018.

https://www.barnesandnoble.com/w/rise-and-fall-of-the-third-reich-william-l-shirer/1100214065#/

[xi] Ibidem as above.

[xii] Nadine Burke Harris, “The deepest well: healing the long-term effects of childhood adversity” January 2018.

https://www.amazon.com/Deepest-Well-Long-Term-Childhood-Adversity/dp/0544828704/ref=tmm_hrd_swatch_0?_encoding=UTF8&qid=&sr=

The SPRINT-MIND study – Control of BP to reduce risk of Dementia

The randomization for the clinical trials of the SPRINT-MIND study was started on November 8, 2010, in 102 sites in the USA and Puerto Rico under the guidance of Dr. Williamson et al. Out of the 9361 randomized participants—mean age of 67.9 years and a female participation over 35%— approximately 91% of them completed one year of follow-up cognitive evaluation. The participants were randomized into two groups: in the first one, half were treated to maintain a systolic blood pressure of less than 120 mm of HG—the intensive group—and the other half was treated to maintain one of less than 140m mm HG—the standard treatment group. The median time of interventions was 3.34 years. Initially designed to end in 2018 the study was ended in August 2015 due to bioethical reasons because the researchers found benefits for the first group.

Individuals confined to a nursing home, with a diagnosis and/or treatment of dementia, diabetes or stroke were excluded form this study. The researchers did not explicitly screen participants for a diagnosis of Mild Cognitive Impairment (MCI) in their selection, which raises the possibility that a few of the participants might have already clinical signs of Dementia at the beginning. Moreover, they purposefully did not include the older patients with several co-morbid conditions, which might actually bear the higher risks of aggressive treatment of high blood pressure—orthostatic hypotension, stroke or ongoing cardiovascular failure. Another example of how trials discriminate against older patients and expose them to unknown grave risks with their cookie-cutter approach.

During a median intervention period of 3,34 years, probable dementia occurred in 149 participants of the intensive and care group and 176 in the standard treatment group; intensive BP control reduced the risk of MCI—14.6 versus 18.3 cases per 1,000 person-years—and the combined rate of MCI or probable dementia—20.2 versus 24.1 cases per 1000 person-years. The trial failed to reach statistical significance on its primary cognitive outcome of a reduction in the occurrence of dementia. Some academics claim that the study failed to reach significance because the testing was cut short and more time should be allotted for follow-up of patients; the Alzheimer’s Association has announced the provision of a U$ 800,000 grant to add two more additional years to the study.

In a Neurology Today article on this study, Dr. Emer R. McGrath said that the technique for obtaining blood pressure readings they had utilized—use the average of three automatic readings with no personnel in the room—might give mischievously low readings than the one in practices. The risk of over-treatment and adverse effects in already frail patients is worrisome indeed. Other practitioners point out that researchers do not know which BP medication might work best and at what age. However, the majority of those interviewed were hopeful that the follow-up study might bring statistical significance to the concept of controlling the BP to avoid future onset of dementia.

We already know that a methodical control of one’s blood pressure as of middle age will make a significant difference to avoid cardiovascular and renal diseases in our older years. Similarly, we believe that the same Wellness interventions will help us at least delay the mind ravages of ageing in order to have a better quality of life.

What do you think? Please tell us.

Don’t leave me alone.