Sunday, December 28, 2008

Guest entry: Multiple personality disorders, a theory

posted by Antigone Kostas, MD (psychiatry resident)

Key Thoughts After Reading Richard Gottlieb's "Does the Mind Fall Apart in Multiple Personality Disorder? Some Proposals Based on a Psychoanalytic Case"

In one of our case conferences, a resident presented a patient with a diagnosis of multiple personality disorder (MPD) to open discussion. However, what we residents very quickly learned from our supervising attendings is that no credible psychiatrist really BELIEVES in multiple personality disorder. Instead MPD is a figment of very suggestible, most often sexually or physically abused people. Therefore when a friend who is not in psychiatry asked to learn more about MPD, I groaned. Nonetheless, I gathered some articles on the subject and was actually surprised to find one that offered an interesting perspective in understanding MPD. Gottlieb takes a psychoanalytic approach to MPD rather than one looking to hypnotize the patient and fuse the multiple selves. Below is his explanation of how MPD evolves.

Gottlieb argues that MPD is not a problem of a disintegrating mind or multiple selves. Rather it is multiple behavioral states (not selves) stemming from fantasies of being multiple people. First he says the person must believe that multiple personalities are possible. This is not a far leap when one considers what happens during trauma and when one dissociates. The dissociating person thinks, "This terrible thing is not happening to me, but rather I am over here as an observer of a different me who is the unfortunate participant, victim...." (Gottlieb 1997) etc. Hence the multiple view points. Also, these people are often victims of sexual/physical trauma who have had their "bodies forcibly intruded upon, entered, filled, and emptied." Implicitly, Gottlieb argues that if someone has had control over someone else's body, someone else could likewise have control over his/her mind. Thus, the emergence of MPD.

Gottlieb, Richard M. "Does the Mind Fall Apart in Multiple Personality Disorder? Some Proposals Based on a Psychoanalytic Case." Journal of American Psychoanalytic Association, 45: 907-932.

Friday, December 19, 2008

Kidney stones (and obesity)

(continued from a previous entry, The excesses of modern life and kidney stones)

4. Weight

The NY Times article “A Rise in Kidney Stones Is Seen in U.S. Children” alludes to the rise in obesity as a likely contributor to an increase in kidney stones but neglects to provide an explanation.

A simple argument, of course, would implicate known risk factors, such as a higher intake of salt and protein and insufficient intake of water, but the assertion of the article and many experts is that obesity increases the risk of kidney stones independent of typical risk factors.

How might that be? The link is insulin resistance.

Insulin resistance

Insulin resistance is the insufficient response of the body to the insulin that the pancreas secretes. That is, normally, in proportion to our meals the pancreas (to assist in regulating our metabolism of food) secretes insulin that initiates important chains of events in our muscle, liver, and fat tissues. In the setting of insulin resistance, the pancreas secretes the insulin, but the body's tissue, rather than jumping to attention and reacting appropriately, merely shrugs. Again, the body is resistant to the insulin the pancreas is secreting. To overcome this indifference, the pancreas must secrete more insulin.

There are several causes of insulin resistance, including genetic, but a growing cause is obesity. (Not all obese individuals develop insulin resistance, and proper diet, exercise and weight loss can lower insulin resistance.)

The problem with insulin resistance is that it is associated with multiple medical problems, such as diabetes mellitus (often the first step on the road to diabetes, developing even decades before diabetes is diagnosed), hypertension, and cardiovascular disease.

Uric acid

Less well known is the association between insulin resistance and high uric acid levels in the body. High levels of uric acid in the blood can lead to the infamous gout, a painful, inflammatory arthritis.

In the urine high levels predispose to kidney stones - not only to uric acid stones but also to almost all other types of kidney stones. Microscopic crystals of uric acid can act as the tiny seed or nucleus around which other minerals are able to amass, thereby provoking the formation of other types of kidney stones.

Bottom line

Obesity is linked to insulin resistance and its association with high levels of uric acid in the urine, which contribute to kidney stones.

(More on insulin resistance in a future entry.)

Monday, December 1, 2008

Kidney stones (and high protein diets)

(continued from a previous entry, The excesses of modern life and kidney stones)

3. Protein

The New York Times article “A Rise in Kidney Stones Is Seen in U.S. Children” implicates recent high-protein fad diets as contributing to the increased incidence of kidney stones.

Specialists of kidney stones and calcium metabolism have long derided the high level of protein in the typical Western diet as contributing to not only kidney stones but likely also to osteoporosis. (Osteoporosis is more prevalent in Western societies - including in immigrants to the West relative to the inhabitants of their native-born lands – suggesting environmental causes.)

Protein as an acid

In the same way that the body functions best with a certain amount of water, at a certain temperature, etc., the body functions best at a certain acid-base level, a certain pH (7.4). As a result the body works hard to maintain this optimal acid-base state.

Proteins, however, are acidic. They are made of amino acids, and therefore eating protein requires the body to buffer these amino acids to maintain the proper pH - a task which it does using buffers in the blood.

The effects of high protein diets

Eating high amounts of protein, however, overwhelms these buffers in the blood, and the body is forced to find other ways to buffer the extra acid. One of the ways it does so is to break down bone. As expected when bone is broken down, calcium is also released, and extra calcium inevitably spills into the urine.

The kidneys, in attempts to rid the body of the extra acid, acidify the urine, but this makes the aggregation of crystals in the urine easier and further predisposes a person to kidney stones. In addition, the extra acid in the body (this metabolic acidosis) lowers the levels of urinary citrate, a molecule that normally attempts to inhibit kidney stone formation.

Bottom line

With high protein diets the resultant acidic urine, low levels of urinary citrate, and extra calcium in the urine all contribute to the increased risk of kidney stones.