Cancer screening

Finally... For those who haven't yet read this article in the NY Times, worthwhile reading.

Cancer Society, in Shift, Has Concerns on Screenings

By GINA KOLATA

Published: October 20, 2009

Guest entry: Domestic violence and narcissist personality disorder

posted by Antigone Kostas, MD (psychiatry resident)

The cycle of violence in domestic abuse: The abusive husband hits his wife and, while the wife may then leave, after many pleas from the husband that he’ll never do it again and that he truly loves her, she’s back with him, for a period of relative peacefulness (the honeymoon phase) - only to be hit again and for the cycle to repeat.

Why does the wife go back to the abusing husband? And who is the abusing husband? In his paper, “Dyadic Violence, Shame, and Narcissism,” Stewart Hockenberry, a psychologist, explores who these people may be and why this happens. He claims that in many situations it is the play between two different narcissistic characters—the Grandiose Narcissist and the Symbiotic Narcissist.

A narcissist is often a person "who is full of him/herself." Narcissists have grandiose views of themselves, often to oddly enough buoy themselves against feelings of low self-esteem. Characteristics of narcissists include using other people for their own gains and lacking empathy.

So, first, how does a narcissist develop? Hockenberry finds that, “Early childhoods are variously characterized by narcissistic injuries linked to abandonment, separation, lack of parent-child attunement, neglect, impingement, and abuse; each shares a unifying theme of profound, inescapable, and self-negating shame.” Thus the narcissist is very much the shamed, wounded child.

The grandiose narcissist hides his shame and feelings of inadequacy by “playing the big man.” Moreover, the grandiose narcissist, because of his shame and self-hatred, finds someone else upon whom he can “project his own frustration and thus dissociate from these feelings of self-hatred. By projecting these feelings onto someone else, the grandiose narcissist can triumph over his internal shame by ‘revenge.’”

In an abusive relationship this plays out usually after the honeymoon phase. During the honeymoon phase, the other person is “loved and idealized as long as domination and complete control of their responses can be assured.” However, when things do not go according to plan, the narcissist feels attacked and strikes back.

The example Hockenberry gives is that of a doting man on a woman who soaks up all the adoration and makes no complaints. As the story goes, this cannot go on forever and when the woman starts to point out needs of her own or to have a few complaints, the grandiose narcissist goes into a narcissistic rage—feeling attacked-- and is ballistic.

But who pairs up with the grandiose narcissist? Hockenberry counters that it is often a narcissist as well - a symbiotic narcissist. The symbiotic narcissist also has shame, but is instead self-deprecating, turning her anger/aggression inward and living by martyrdom. She often feels responsible for other people’s pain and anger - suffering becomes familiar and even natural.

The symbiotic narcissist was “raised in control-oriented, oppressive environments, in which at least one of the parents was intrusive or invasive of personal boundaries, [and] the individual attachments are tenuously maintained, often at the cost of considerable pain and suffering. Because of overwhelming needs for attachment and bonding, actual abuse and suffering are frequently denied or are seen in themselves as signs of attachment.”

So the grandiose narcissist seeks out those he can degrade when the situation feels out of hand, while the symbiotic narcissist eats up the suffering. Hence the cycle of attack/revenge and victimization/suffering continues.

Bibliography

Hockenberry, Stewart L., “Dyadic Violance, Shame, and Narcissism,” Contemporary Psychoanalysis, Vol 31, No.2 (1995).

Alzheimer's, dysphagia, and PEG tubes – a conversation

Grandpa had been gradually declining from Alzheimer's dementia for years (he was confined to bed and he could no longer communicate with his family), but on this visit, after he was admitted to the hospital with pneumonia for the second time in a few months, it was clear he was now also having difficulty swallowing (dysphagia in medical terms). Grandpa was choking on the simplest of foods, including liquids and pureed foods, when he was tested by the speech therapist. Even when slowly fed small spoonfuls he wasn't safe to eat.

(image of pneumonia by Tim Snell, http://www.flickr.com/photos/timsnell/2347749472/)

“How will he get food?” the family asked.

“We have a couple of options,” the doctor began. “One is to entirely bypass his mouth and throat, where all the difficulty is, by placing a tube, a PEG tube through the skin of his abdomen directly into his stomach. The tube can then be used to feed him, give him medicines, etc.”

“Is that major surgery?” the family asked.

“Although not without risks, it's a relatively simple procedure. The gastroenterologists place PEG tubes relatively often and serious complications are rare. The procedure is performed by passing a camera through the mouth down into the stomach, in the same way that upper endoscopies (EGDs) to view the esophagus and stomach are performed. There the gastroenterologists shine a light up at the skin and where that light is seen on the skin is where they place the tube.”

“Sounds worth doing,” the family said.

“From what I've told you so far I'd have to agree, except as usual nothing is quite so straightforward. For instance, there is some controversy as to how effective the PEG tube truly is in patients like Grandpa, whether the tube truly prevents aspiration (food going into the lungs) any more than merely trying to carefully feed him by mouth slowly and with small spoonfuls.

Despite all of us having a sphincter or valve at the lower part of our esophagus to keep stomach contents from coming back up, we all at some point during the day, usually at night, likely allow some stomach contents into our lungs. We aspirate. Similarly, even with the PEG tube some of the contents from Grandpa's stomach will find their way into his lungs. The difference between us and Grandpa, though, is that we are able to protect our lungs. If food or stomach contents go the wrong way, we quickly cough them up. Grandpa can't as I'm sure you've noticed by his really weak cough.”

“So if we don't place a PEG tube?” the family asked.

“The other option is to merely let Grandpa eat and accept the fact that some food will likely go the wrong way and into his lungs with all the risks that entails, including more pneumonias and potentially death.¹

Sounds terrible, I know, but where we are now with Grandpa, with dysphagia and food going into his lungs, is part of the natural progression of Alzheimer's. It is common and generally signifies that the Alzheimer's patient is severely impaired and that life expectancy is short. And the benefit of placing a PEG tube in a terminally ill patient, sadly, is unclear.

Knowing that, not everyone would want an artificial feeding tube.² In fact, letting Grandpa eat and take those risks is a reasonable option, and one that many families choose.³

The question in the end is what would Grandpa have wanted? If Grandpa were able to be here today and tell us, what would he say?

“I have a question,” one family member asked, “If we place the tube, can he still eat?”

“While he can still eat with the PEG tube, the main reason for us to place the tube, would be to try to minimize his risks. It would make less sense in Grandpa's case to both place the tube and let him eat.

If we do choose to allow Grandpa to eat, however, knowing that Grandpa will continue to develop pneumonias, I would suggest that the next time he does that we don't actually transfer him back to the hospital. Rather than us at the hospital trying to help him recover from that pneumonia in order to be healthy enough to go through the process all over again, I would leave these issues to his regular doctor to manage and, if necessary, to make Grandpa comfortable. It is another difficult decision but one worth considering...

Another way to think about these issues is what do we really want to accomplish? PEG tubes, for instance, make for easier delivery of medications, but if we are trying to have Grandpa live longer or have a better quality of life, that may be unrealistic.”⁴

1We all pass at some point and pneumonias are a common way in which we pass.

2You would think that swallowing is as hardwired as anything else in our body, like a reflex or our heart beating, something that requires no thought and would never go, but that isn't true. It actually requires a level of brain function to effectively coordinate all the movements of swallowing: to chew, push food to the back of the pharynx, initiate the swallow, etc.

3Nutrition is seen as a symbol of life and withholding full nutrition, in some way letting a family member go, letting them pass, even if naturally, can be difficult for families; yet, in many ways this dilemma developed only as a result of modern technology, our ability to place feeding tubes, give antibiotics, etc.

4An unintended consequence which people don't usually consider is that every time Grandpa returns to the hospital and is treated for pneumonia with antibiotics, the risk of creating more and more drug resistant bacteria increases. The fear from a medical and societal perspective is the development of bacteria potentially resistant to all known antibiotics.

(Brief) Reaction to Article: "Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease"

"Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease" by Patrick W. Serruys, M.D., et. al. (New England Journal of Medicine (NEJM), March 5, 2009)

I was drawn tonight to the above NEJM article by an article posted on the New York Times (NYT) website, "Heart Stents Found as Effective as Bypass for Many Patients" by Roni Caryn Rabin. This NEJM article has yet to be published in print but was published in advance online.

My first two reactions to the study (and there were many others but these I feel are the most important) :

(i) The follow up of patients was only for one year. I suspect the majority of us are hoping to live much longer than one year after our procedure... Follow up at, let's say, 5 years would be much more valuable, and I think much more revealing. There are usually two periods of divergence between patient groups that we see when evaluating vascular surgeries - such as evaluating the benefits of placing stents versus performing surgery with carotid stenosis (blockages of the arteries that supply blood to the brain and increase people's risk of strokes): early on and long term. Surgeries typically have higher risks early on but lower long term, and with stents the reverse is typically true. Thus, a further divergence between patient groups after one year would not be a surprise to the medical community.

(ii) There are significant differences between the medicines the two groups received after their procedure (even simple medicines like aspirin and cholesterol lowering medicines like statins - drugs that we know reduce strokes, heart attacks, etc.) I encourage you to look at Table 2 of the article and compare the two columns, PCI (patients receiving stents) and CABG (patients receiving surgical bypasses). The patients who had bypass surgery consistently, in regard to each of the medicines listed, were less like to receive the medical standard of care. Those differences make the comparison between the groups of patients much more difficult. Rather than comparing apples and apples, the study is forced to compare more apples and oranges. One wonders at how the two groups would have differed if they had both received the general standard of medical care after their procedures. Perhaps the surgical bypass patients would have done even better. One would expect so.

By the way for the women out there, 78% of the study participants were men - a flaw that continues to plague studies, even today.

If you are interested, I encourage you to attempt to read the article - you will understand more than you think and be able to make your own opinions. If not, I encourage you to read the editorial accompanying the article, Coronary Revascularization in Context by Richard A. Lange, M.D., and L. David Hillis, M.D. (NEJM, March 5, 2009).

Consumers should be aware of the limitations of what they read and are told. For those interested, previous entries on related subjects: The almighty cardiac stent and Reaction to Article: "Communicating Medical News -- Pitfalls of Health Care Journalism".

Placebos, doctors, and fibromyalgia (Addendum)

As discussed in the last entry, one of the problems with surveying doctors' prescribing habits in treating fibromyalgia is that it disregards the controversy surrounding the diagnosis. Therefore, does doctors' use of placebos in treating fibromyalgia really represent their general use of placebos? Published online today is an article that elucidates further the skepticism that surrounds this diagnosis.

For those interested: "Drugmakers' push boosts 'murky' ailment" written by Matthew Perrone, AP Business Writer.

Placebos, doctors, and fibromyalgia

A placebo, according to the American Heritage Dictionary, is “a substance containing no medication and prescribed or given to reinforce a patient's expectation to get well.”

When we think of placebos, we generally think of sugar pills; however, the concept of placebos has evolved to include pills with active ingredients and more broadly any “treatment whose benefits (in the opinion of the clinician) derive from positive patient expectations and not from the physiological mechanism of the treatment itself.” (BMJ 2008;337:a1938; Prescribing "placebo treatments": results of national survey of US internists and rheumatologists).

Using this broad definition, a group of researchers set forth to study the current practices of U.S. doctors in prescribing placebos. Its study results, published in the British Medical Journal (BMJ) in October 2008, were reported in all the major newspapers, including an article in the New York Times.

The study, as it was reported, found that approximately half of the American internists and rheumatologists surveyed regularly prescribe placebos.

While the general public likely was surprised by these results, as some doctors might have been, anyone reading the actual study likely was not. Despite the suggestion that the study surveyed the general attitudes and behaviors of physicians in prescribing placebos, the study actually asked the questions specifically in the framework of fibromyalgia.

Fibromyalgia

Fibromyalgia is a poorly understood condition of chronic pain over multiple muscle and soft tissue areas of the body often accompanied by nonspecific symptoms, such as fatigue, headache, and sensation of joint or tissue swelling. The symptoms of fibromyalgia occur with varying severity and can be aggravated by various factors, such as stress or poor sleep.

While a physical exam reveals tender points located symmetrically on both sides of the body, the patients look healthy and have no other real findings on exam, labs, or x-rays. Once other potential diagnoses are excluded, the diagnosis of fibromyalgia is made.

What causes fibromyalgia? We don't know. How best to treat it? We don't know.

Some studies suggest that prolonged sleep deprivation can cause symptoms similar to fibromyalgia, but many patients with fibromyalgia do not have sleep disturbances. An association of fibromyalgia with mood disorders has led some doctors to attribute the symptoms to psychiatric causes, but again the majority of patients with fibromyalgia do not have psychiatric disorders. In part because co-existing illnesses can confound the diagnosis, a clear explanation for fibromyalgia does not yet exist.

The current explanation for fibromyalgia is that the brains of patients with fibromyalgia are overly sensitive to the nerve signals emanating from the patients' muscle and soft tissues and, as well, over-interpret these inputs as pain. (There are parallels here with irritable bowel syndrome.)

Despite this knowledge and the knowledge that patients with fibromyalgia suffer from real pain, doctors in general, without any objective findings in their patient, have a hard time understanding the disorder and treating it. They tend to see fibromyalgia as in their patients' heads and can become as frustrated as the patients in trying to treat the chronic pain.

Treatments for fibromyalgia

The available treatments for fibromyalgia include patient education, aerobic exercise, muscle strengthening, cognitive behavioral therapy, and, of course, medications. The medications are of varying but limited benefit and include some tricyclic antidepressants, serotonin reuptake inhibitors (SSRIs), anticonvulsants, and muscle relaxants in combination with acetaminophen (Tylenol). Consistent with a lack of evidence for muscle or tissue inflammation in fibromyalgia, there is generally no benefit from anti-inflammatory agents, such as NSAIDs (a group of pain relievers that include over the counter medications such as ibuprofen and naproxen) or prednisone. The prescribing of narcotics other than tramadol are usually avoided due to a lack of evidence and a concern for long-term abuse.

A look back now at the BMJ study

The study surveyed doctors to explore current practices in prescribing placebos. Despite how the study was reported in the lay press, the questions were asked in the framework of treating fibromyalgia. Given what you now know about fibromyalgia (a condition of chronic pain with an unknown cause that is difficult to treat) are you as surprised by the study results? Clearly, if the study asked the questions in the framework of other diagnoses, such as rheumatoid arthritis or heart disease, you would not expect half of doctors surveyed to report regularly using placebos.

The study revealed the use of the following placebos: over the counter pain relievers (41%), vitamins (38%), sedatives (13%; usually implies benzodiazepines or 'valium-like' medicines - drugs that soothe or calm and can induce sleep), antibiotics (13%), saline (3%, salt water), and sugar pills (2%). Saline and sugars pills, in not containing active ingredients, were the only two placebos in the traditional sense of the word and made up 5% of cases in which placebos were used (not 5% of doctor-patient encounters for fibromyalgia).

Risk-benefit analysis

As observed in the study, the placebos of today are generally not sugar pills but pills with active ingredients. In fact, obtaining sugar pills from pharmacies is now extremely difficult as very few pharmacies will, and only on special request, make them – it requires time and know-how. I suspect doctors' fear of being sued also plays a role in the prescribing of more active than inactive placebos, as a medicine with an active ingredient appears more easy to justify.

The beauty of sugar pills, of course, is that they carry little risk to the patient. If ultimately the patient and doctor want the patient to feel better and if a pill, whether a placebo or not, can be effective with little risk to the patient, then the risk-benefit analysis would seem to favor giving it.

There are obvious risks, however, in prescribing medicines with active ingredients: side effects, allergic reactions, interactions with other medicines the person is taking, etc. The use of antibiotics in the study as a purported placebo in treating fibromyalgia is, therefore, of a bit more concern. The antibiotics were presumably prescribed to allay patients' fears of Lyme disease or other chronic bacterial infections, reflecting unfortunately already known inappropriate use of antibiotics (see past entry: Antibiotics and the common cold). Without evidence of a clear bacterial infection, a risk-benefit analysis, particularly in fibromyalgia, would of course generally not favor antibiotics as they may lead to real, potentially serious medical problems.

A placebo effect for doctors?

Placebos are not only for patients, though. They can be for patients' families and even the doctors themselves. While doctors in the study may have justified the use of antibiotics as placebos for their patients, they very well may have been treating themselves - perhaps their own concerns about missing a diagnosis behind persistent, nonspecific complaints or a desire to discover a fortunate, effective and sufficient treatment for the patients' problems.

Less discussed is this idea that sometimes in prescribing specific treatments to patients, doctors are actually, in essence, treating themselves or treating themselves in addition to the patient – when, to rework the earlier definition of placebo, positive doctor expectations may outstrip the known benefits from the physiological mechanism of the treatment itself. The doctor's desire to help the patient get better or be more comfortable may at times be too great.

Of course, not for naught, positive doctor expectations may lead to positive patient expectations and treatment benefits via the placebo effect.

A few more thoughts from the study

The authors of the BMJ study on placebos bring up two additional interesting and unanswered questions for discussion: the ethical considerations of prescribing placebos and whether placebos work if patients know they are taking placebos.


Thoughts?

Guest entry: Suicide, psychiatry, and fiction

posted by Antigone Kostas, MD (psychiatry resident)

It's been insidious. Having been on vacation from psychiatry residency for a week with more time to peruse fiction selections, I have noticed a change.

At one point in a story I was reading the narrator noted that he and another guy "just ended up" peeing together behind a tree. He mentioned this detail in passing, as a segue to the conversation they had while peeing, but whoa! How does something like that happen? What happened to personal space and the fact that a whole field (without a mention of a paucity of trees) does not necessarily situate these urinals naturally next to each other? Suddenly, a major red flag appears. Details I would have normally glossed over, I now can't.

Way too much Freud.

In addition, since working in the psychiatric ER, I have learned not to dismiss things. I have learned to ask very specific questions and not to leave things to vague feelings. At first, I admit, I didn't see the point ("They're suicidal, they swallowed a bottle of pills, for god's sake hospitalize them!!"), but we can't hospitalize all the suicidal patients

¹, especially those with borderline personality disorder² when the events were just an acting out.

People with borderline personality disorder don't have a strong sense of 'wholeness.' Much of what they feel internally comes from what is going on externally, and as a result they cannot regulate their own emotions very well. They don't tolerate frustration well so they may jump from the extremes of being very angry to being okay. While they were in the throes of a very strong emotion when they tried to commit suicide, they just don't feel that way anymore. Borderlines often have multiple suicide attempts in their history and some actually do die, usually because they misjudged the lethality of their attempt, but more often the attempts are a cry for help or an acting out.

In the course of examining suicide attempts, innumerable questions arise. How serious was the attempt? How many pills did they take? What was it? For example, Benadryl is less serious. Did they take it in front of someone in a melodramatic gesture? Who found them? How were they found? Did they leave a note? A note is more serious and suggests they were not just acting in the heat of the moment. Have they attempted suicide before? What were their other suicide attempts like? Are they repetitive incidences of acting out or are they all serious attempts? Can they keep it together now in the psychiatric ER?

In the ER, as psychiatrists, we have to probe the patients' motivations at each step, study their current affect and decide whether we think they're serious about making another attempt. It can be tricky (and there's no guarantee that someone might not act unpredictably and try suicide again...), which is why we really have to make sure we probe every detail and make sure we don't miss something the patients are trying to hide.

This is the reason why now, reading fiction, if I read an odd description and the author does not explain the context or motivations of the characters, I feel like I am being duped. I cannot easily go on, gloss over for the sake of fiction, because the whole premise is false. It would never happen! There needs to be context... Instead of location location location, it's now context context context!

.....

1We can't hospitalize all the suicidal patients in part because there are too many of them.

2Borderline personality disorder is a complex syndrome and includes some of the following diagnostic criteria:

"– dramatic efforts to avoid being alone
– a pattern of intense unstable relationships
– disturbances of self-image
– self-damaging acts
– suicidal threats or gestures
– marked emotional instability
– persistent feelings of emptiness
– difficulties with controlling anger
– thoughts of persecution or episodes of dissociation”

(Robinson, David, J. Disordered personalities. Rapid Psychler Press, Michigan: 2005)

Reaction to Article: "Communicating Medical News -- Pitfalls of Health Care Journalism"

Communicating Medical News -- Pitfalls of Health Care Journalism by Susan Dentzer (New England Journal of Medicine; January 1, 2009)

The article above, printed in the “Perspectives” column in a recent issue of The New England Journal of Medicine, reviews the failings of heath care news and challenges journalists to offer a more complete picture and resist the urge to sensationalize and oversimplify the news. I recommend that every consumer of health care news read the article as it provides an important perspective.

The article will also give readers a better appreciation for the frustration that doctors experience reading health care news in the lay press, realizing the misinformation that readers digest, and knowing the time and energy they then must spend attempting to correct mistaken notions.

The bottom line: read health care news with a good degree of skepticism. (Despite journalism's best intentions, the media industry is ultimately in the business of making money. Health care news, whether fully accurate or not, sells and increased sales bring more money.)

Turns out our mothers were right: why we should eat slowly and fully chew our food

In talking with gastroenterologist friends about being on call this holiday season, they humorously note the number of times they inevitably are called by the Emergency Room to see patients in whom food has become lodged in their esophagus.

Swallowing

In the normal act of eating, after chewing our food, a bolus is transferred from the back of our mouth to our pharynx and then to our esophagus. Once in our esophagus the food is pushed along to our stomach by peristalsis, organized contractions of the muscles of the esophagus. (a graphic illustration of the swallowing process, www.hopkins-gi.org/multimedia/database/intro_250_Swallow.swf)

Holiday hiccups

In our holiday zeal on seeing all the delicious, prepared goodies (after starving all day in anticipation), we inhale our holiday meals, but several unlucky individuals among us will get a large piece of food stuck in their esophagus (the size of the food bolus overwhelming the muscles of the esophagus) and be found by a gasroenterologist uncomfortable, lying on a stretcher in the ER in search of relief.

The remedy

The patients are brought to the Endoscopy Suite where the gastroenterologist passes a flexible tube with a camera at its end (an endoscope) through the mouth and down the esophagus to where the food is lodged. Once there, typically, the gastroenterologist simply pushes the food through the rest of the esophagus to the stomach where digestion will aid it's transit through the remainder of the digestive tract...

Not always a laughing matter

On a more serious note the procedure, an esophagogastroduodenoscopy (EGD), like any other procedure has its own risks, including the potential for rupture of the esophagus – a steep price to pay for time otherwise spent eating slowly and enjoying a meal.