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Arnold Tweed - Page 2 of 6 - medical misadventures

A Visit to the Doctor

Arnold Tweed 

In my early years I supplemented my income by doing locums in rural areas, filling in for the local doctor. A locum is a temporary fixture, not part of the community, and consequently not acquainted with its customs. For a city boy this would be a daunting experience; country folk describe their health and medical problems in a manner that often leaves the listener baffled. Fortunately, I was born and raised in rural Manitoba and the discourse of country people was second nature to me. The key is to understand their main obsession – which is to give nothing away. Only essential information is revealed, and that grudgingly. They control the information flow so that the doctor, or anyone else listening, hears only what they want him to hear.

The location of this encounter is of no importance; it could have been anywhere west of Winkler to the Saskatchewan border. My first patient that morning was Mr. Alvin Jones, age fifty, a farmer. The file handed me by the receptionist was blank; this was his first clinic visit. Mr. Jones is, of course, a fictional name. He entered the examining room hesitantly, politely removed his John Deere cap, and waited until I motioned him to a chair. If you know where the John Deere Implement Company has the largest dealership in rural Manitoba you will have identified the town.

I believe in the adage that first impressions count, so I prepared carefully for locums – newly starched lab coat, name tag, white shirt and tie, fresh haircut. He was also dressed for the occasion (probably by his wife): clean shirt, dress shoes and a new cap. From my vantage point behind the desk I could sense that he was uncomfortable. He didn’t look at me directly but glanced about as if looking for an escape route.

But time was pressing and there were already a dozen patients in the waiting room. I started briskly. “Good morning Mr. Jones. I’m Dr. Tweed and it seems this is your first visit to this clinic.”

“I guess so. Where is the old doc, Dr. Petkau?”

I explained to him that Dr. Petkau was attending a refresher course, and then taking some vacation, and I was his substitute for two weeks. This established, I was ready to get down to business. With a new patient it is generally useful to get some information about past medical problems, so I like to start with a brief medical and surgical history.

“Right, Mr. Jones. Have you ever been sick in the past or had any surgical operations?”

“Yeh, once in a while.”

“And what sort of sickness have you had?”

“Oh, the usual things.”

“And operations?’

“No.”

“Now, by the usual things, what exactly do you mean?”

Hesitation. “Oh, the sort of things kids get.”

“You mean you’ve had the usual childhood diseases: mumps, measles, chicken pox?’

“Yeh, I guess so.”

“Right, Mr. Jones and what brought you here this morning?”

“Oh, my wife drove me.”

“Well, yes Mr. Jones, I’m happy to hear that. What I really meant was what did you want to talk to me about?”

“Ah! I came in to ask you about a little problem I have.”

“Oh, and could you describe this problem?’

“Yeh! I guess I could.” There followed a long pause during which he gazed at the ceiling as if seeking divine inspiration. I grew impatient.

“Yes, and if you were to describe it, what would you say?”

“Well, I ain’t feeling very good.”

“Not feeling good, and how long have you not been feeling good?”

“Oh, quite some time.”

Would you say days, weeks, months?’

“Yeh, something like that.”

We were now about five minutes into the medical history, on a busy clinic day, and I had learned almost nothing about Mr. Jones or why he was here. Either he was especially obtuse, or remarkably stupid, or he was hiding something. Perhaps he had a medical issue or concern that he was afraid to mention, something he hoped I would guess without his having to admit to its reality. Or, as an afterthought, perhaps he was testing me. It is a notion held by some country folk that, if the doctor is so smart, especially a young doctor, he should be able to figure out what’s wrong with you – you shouldn’t have to tell him. It was time for the more tedious but reliable method of direct questioning.

“Now, Mr. Jones I am going to ask you some specific questions about your current health. I just want you to answer yes or no. First, do you have any pain?”

“No, not right now.”

“Was it because of a pain that you came to see me this morning?”

“No.”

“Was it because of a sexual problem?”

“No.”

The list could go on, but would continue until I got a yes.

“Is it because you are feeling weak or tired?”

“Yeh. That’s it. I can hardly walk to the barn before I get tired.”

We were now about ten minutes into the medical history and starting to make some progress. His chief complaint, with which we usually begin a medical history, was fatigue. In a fifty year-old man there are many causes for fatigue, but at this pace further history taking was a poor investment of my time. Next step was a physical examination and some basic lab tests. The physical examination showed nothing abnormal, the lab tests were scheduled, and I advised him to come back next week.

Next week he was a little more talkative, either because he had tested me enough or because he was more worried.

“Good morning, Mr. Jones. How are you today?”

“Oh, about the same.”

“Are you still feeling tired when you walk to the barn?”

“Yeh.”

He looked hopeful, but my news was not good. His laboratory tests were unremarkable, except for one. He was seriously anemic – his hemoglobin level was much below normal. Fatigue and anemia in a man his age was probably due to chronic internal blood loss. The most likely site was the large bowel.

“Mr. Jones, I have to do a rectal examination. That means I put a finger in your rectum to feel around. But first tell me, has there been any change in your bowel movements?”

His response was immediate; he didn’t have to look at the ceiling for inspiration or concoct a vague rejoinder. This had obviously troubled him but the color of one’s shit is a private issue, not a medical problem. How could there possibly be any relation between black shit and feeling tired?

“Yeh, I’ve had some black looking movements in the last couple of months. Does that mean anything?”

The rectal examination did not reveal a tumor within reach of my index finger, but his stool was black and the guaiac test, the test for occult blood, was positive. Whether the growth in his large bowel, the cause of his anemia, was or was not malignant could not be determined at this stage. He needed a surgical consultation, a biopsy and probably a bowel resection. I had done all that I could do.

Once all his cards were on the table and the bad news was out Mr. Jones was a different man. He seemed relieved of his burden and wanted to move ahead. Harvest was coming up; but how would he manage? Should he keep his son home from college? Who would reasonably expect a modern 18 year-old to obligingly miss a year of college to help on the farm? College life is much more rewarding, and exciting, than life on the farm. What should he tell his wife? If he delayed the operation until winter would he recover in time for spring seeding? Seeding and harvesting were the milestones in a farmer’s year, everything else took second place.

Of course, I had no answers to these questions, but discussing them seemed to take priority over his immediate treatment. We parted on amicable terms and I never saw him again.

His candidness in the face of reality was in striking contrast to the evasiveness of our first interview. Why are some people so vague and find it so difficult to discuss their medical problems? Perhaps they simply lack the vocabulary; just as some lack a vocabulary for sexual discussions – except for one universal descriptor of course.

Perhaps they fear the answer or are testing their doctor to judge whether he merits their trust. But I believe that it is more likely a product of the natural reticence of country people. In a small, gossipy community privacy and confidential information are carefully guarded. One doesn’t air his private affairs in public, no matter how long he has known his neighbours. They may know all your secrets, but they will never admit that to your face. You don’t boast about your bank balance, or spend money ostentatiously. You never discuss intimate topics, except in the privacy of your bedroom. And you don’t disclose your medical details to a stranger, even if he is a doctor. And certainly not if he is a smart-ass young doctor just out of medical school.

 

 

Technical notes: The guaiac fecal occult blood test (gFOBT) is one of two simple tests for occult (hidden) blood in the stool, blood that is not visible on the surface (the newer test is the fecal immunochemical test (FIT)).  Guaiac paper for the test is prepared from the wood resin of Guaiacum trees, a tropical tree commonly known as lignum-vitae. In addition to its lumber and ornamental values this tree has found several medicinal uses, now only of historical interest. Gum from the wood was used to treat syphilis in the 16th to 18th C, as well as arthritis and cough (guaifenesin). The latter may still be found in some cough preparations.

Black, tarry stool indicates serious bleeding higher in the gastro-intestinal tract. Both the gFOBT and flexible colonoscopy are recommended as screening tests for bowel cancer in the 50-75 year age group.  There are arguments pro and con for each, but the gFOBT is simple, non-invasive, inexpensive, requires no anesthesia, and can even be done at home. In 2006 the NHS in the UK introduced a bowel cancer screening program using gFOBT. They reported that it was associated with a 15% reduction in mortality (Koo, Neilson et al. 2017). The gFOBT will soon likely be medical history only, replaced by the more sensitive FIT test.

 

Koo, S., L. J. Neilson, C. Von Wagner and C. J. Rees (2017). “The NHS Bowel Cancer Screening Program: current perspectives on strategies for improvement.” Risk Manag Healthc Policy 10: 177-187.

Near-death Experience

Near-death Experiences

Arnold Tweed

To look death in the eye, and, at the last moment, be pulled back, is an immensely moving experience. It is no surprise that many who been that close to dying have fantastic stories to tell. Each story is unique but there is a commonality, which modern writers call the near-death experience (NDE). Medical scientists – psychiatrists, psychologists and neuroscientists – have struggled to find explanations for the NDE which fit the medical model. Spiritualists insist that it is the wanderings of a conscious soul, which leaves the dying body to seek another world, but is called back. To date neither side has proven their case, nor disproved the other.

Today’s hi-tec medical interventions have made the NDE commonplace, and vivid reports engage a growing audience – literally a cult following – with thousands of cases recorded on one web site (NDERF.com).  Books and articles, often based on personal experiences, overflow the bookshelves. You can participate in national conferences and a week-long course to imitate the experience.

With so much hype one would suspect that these reports are pure hoax. You get a different impression when you talk with someone who has been there. Brian Moore is an intelligent and practical man: a successful businessman, developer and municipal politician. Now 74 years of age, he has been a member of the Anglican Church all his life and a regular church goer. But when asked about his beliefs he admits he was sceptical about heaven, hell and an afterlife. That is, until 26 September 2015. This is his story of that day as told to me about two years later.

We talked in his office, in the building supply center he owns. Brian looked up from his laptop when I entered, leaned over his desk and stuck out his hand as if I was the most welcome visitor he had that day. He was a bit hazy on the medical details, as expected, but the rest of his story needed no prompting. The clarity had not faded, but he struggled at times to find words to describe images and feelings that were so extraordinary. This appears to be a common difficulty and some call these experiences ineffable, literally beyond our powers of description.

 

Brian’s story:

….. “The day started much like any other working day. I was helping a customer load cinder blocks onto his truck, perhaps a bit too strenuous a job for a man of my age. Not that I had any health concerns, I still did a full day’s work. However, when I got back to my desk, sitting in my chair, catching my breath, I was seized with the worst pain I have ever felt – a crushing chest pain that left me cold and sweating. I called out to my secretary and, after one look at me, she called the ambulance.

Fortunately, we live in a small town – Killarney, Manitoba – and within about fifteen minutes I was in the hospital emergency room. The doctor on call checked my pulse and blood pressure, then immediately put in a call to the senior hospital doctor, Dr. Anton Pio. I remember both her urgency and the voice of Dr. Pio as he answered his phone. My next conscious memory was waking up in St. Boniface Hospital in Winnipeg, several hours later.”

A lot happened during those hours, events that changed Brian’s life. This is what he has pieced together from his doctors and nurses.

“This is what I was told happened. I had a cardiac arrest, my heart stopped for ten minutes. They did CPR – chest compressions – and other measures to restart my heart, including eight electrical shocks (defibrillations). And they called the air ambulance to med-evac me to the cardiac unit at St. Boniface Hospital in Winnipeg. Later I was told they didn’t expect I would make it alive; I was unconscious the whole way. In the hospital I guess I went directly to the cardiac room where they found a complete occlusion of the main artery supplying the left side of my heart. Fortunately, they were able to stent it successfully, but I don’t remember any of this. My first conscious recollection is waking up in my hospital bed. But I do have vivid recollections of events during this time,”

This is the NDE that Brian described, an experience that seemed real to him.

“At some point between hearing Dr. Pio’s voice in Killarney and awakening in St. Boniface Hospital I sensed I was in a tunnel. It felt like I was at one end of a tunnel and floating up. The tunnel was dark but the walls were brilliant, a kaleidoscope of color. At the top was a dazzling white light and as I approached it the light got brighter. I didn’t believe a light could be so bright. Not only did it get brighter, but it began to radiate warmth and love; I felt loved; I didn’t want to come back.

But I guess I did come back because I recall looking down at myself. I could see the outline of my body; I’m sure it was my body even though I couldn’t make out the face. I was black or in shadow, lying on my back with arms outstretched above the head.”

I asked him how he explained these visions?

“To me they were real, very real, not just dreams. I knew that was my body, though I couldn’t see the face. The light, I am sure, was God, and the closer I got the more I could feel his presence.”

On his third day in hospital Brian had another experience.

“ It was evening – I was lying awake – when suddenly the end wall of my room became bright blue sky. A golden ball went across that sky trailing a golden streak. Again, this was lucid and vivid, and I believe it was God’s reminder to me that I had been saved for a purpose.”

When I asked if this had affected his life he replied without hesitation.

“This has definitely been a life-changing experience. When I was young I was terrified of death – not just of my death but also of losing my parents. When I was five or six years old I would wakeup crying. My mother would comfort me and ask what was wrong, but I never told her that I was dreaming of dying. Now I have totally lost my fear of death. I’m not in a hurry to go but I have no dread of the prospect. I am thankful for the life I have been given and am sure that there is a God and an afterlife. What form they take, I do not know, but I have experienced the welcome that they offer.”

Has it made him a different person?

“Yes, this experience has changed my understanding of my purpose on earth and my goals during my remaining years. I am more thankful for the blessings of life and I believe I am more understanding and tolerant. At first, I was reluctant to talk about my NDE – I didn’t even know the name for it then – but my church and other neighbouring churches, and community groups, have asked me to share the experience with them. A few weeks ago, I was invited to talk to the congregation of a small Mennonite church at a nearby town, Mather, Manitoba. After the service an old Mennonite gentleman, not somebody I knew, sought me out.  He shook my hand, thanked me and said that my talk had given him great comfort. Three weeks later I was surprised to hear he had died; he hadn’t told me he had terminal cancer.

I have thought about this man and his gratitude. If my message was a comfort to him, could it also be a comfort to others who are near dying? Should I share my experience with others? Was giving comfort and hope the mission for which I was spared? God does work in wondrous ways!”

 

…………………………………

Several authors have catalogued these experiences and identified the features which set them apart (see technical notes). Although each story has its individual peculiarities, they share remarkable similarities. Brian’s account is typical of the majority. Most describe the experience as remarkably vivid and realistic – not like a dream; and not just realistic but a positive, life-changing event.

About 10-20% of people resuscitated from cardiac arrest report a near-death vision and, about 80% of those describe the event in positive terms, associated with feelings of detachment, levitation, serenity, security, warmth, light, and love. Recognition of ancestors or spiritual figures and reluctance to return to the body are common. Those who have had positive experiences believe they have been changed for the better, and report enhanced love for life, serenity, tolerance, and a more charitable outlook.  These are clearly transformative experiences and we would like to understand them better, but where does one begin?

One approach to understanding the unfamiliar is by comparison. We all carry a set of vivid memories – memories of the surprising, dramatic and dangerous events of our lives. These are usually emotionally charged events with deep personal significance – a parent’s death, car accident or near-miss – and they often pop-up in our minds unbidden. Psychologists have named this type of memory “flashbulb memory”. Recall of a flashbulb memory usually recaptures both the details and the emotional aura of the original incident. Almost every one of my generation can remember the day J.F. Kennedy was assassinated – where we were, what we were doing and the feelings of shock and disbelief. The same holds for the 9/11 attacks; say “9/11” and everyone can recall the appalling pictures of passenger jets crashing into the World Trade Center.

Are NDEs just another type of flashbulb memory? If so, they are much more complex. Flashbulb memories are anchored in space and time. They can be spatially fixed by reference to concrete objects in the surroundings, by time and by independent observers. An NDE has none of those. The visual images of an NDE are other-worldly, sense of time is distorted, and independent corroboration is impossible. Although those who have had an NDE report it as real, they are describing a reality that cannot be confirmed by veridical evidence.

Most investigators do not question the accuracy of recall; their interest lies entirely in the mysteries of their origin and meaning. The psychological explanation is that these are dissociative mental states or states of consciousness that fall under the general categories of dreams, delirium, or hallucination. In the psychological model they unquestionably arise from the brain and can be imitated by certain drugs, for example the anesthetic drug ketamine.

The spiritual explanation is that they are transcendent experiences, psychic or paranormal evidence for duality of soul and body. Those with strong religious or spiritual beliefs see them as proof for a soul, for an afterlife, for God and for Heaven. This is not a scientific proof of course; it is an intuitive proof. Intuitive proofs are ideas felt so strongly, so clearly, with such surety, that they cannot be denied. intuitive certainties need not be based on logic and, therefore, scientific attempts to confirm or reject them are irrelevant.

Sceptics scoff at the spiritual explanation. To claim these visions as proof of anything offends the non-believer’s intuitive certainty that science will eventually explain everything that needs to be known about life and death.

Both sceptics and believers, busily defending their own intuitive certainties, have missed the key point. These are transformative personal experiences. Their value is not that they support one world-view or another, it is in the personal benefits – the change in values and outlook of the one who has had the experience.

In determining the worth of an NDE, we all work from the same page, the personal account. Those of us who have not had the benefit must listen to those who have – there is no other way to study them. They are never described as abstract notions, they are highly significant individual experiences, with profound personal meaning and consequences. In his first book in 1975 (see technical notes), Raymond Moody recognized that the personal significance was the real value: “However, more than academic and professional issues are involved. It involves deeply personal issues, for what we learn about death may make an important difference in the way we live our lives.”

William James, one of the most influential American scholars of the late 19th Century said much the same. In The Varieties of Religious Experience, written in 1902, he stated that a revelation or transformational experience could only be judged objectively by its effects. He also insisted that we judge the contribution of the experience by human standards of value, by its contribution to human welfare. If the effects were beneficial – if the recipient became a better and happier person, or if there was a benefit to society – it was a valuable experience.

These are events of great personal consequence which alter the affective and intuitive aspects of consciousness. Personal attitudes and intuitive understanding of life and death are changed. One remarkable consequence, reported by almost all, including Brian, is complete loss of the fear of dying. They do not invite death; but they no longer dread it. They interpret their NDE as assurance of a continued existence? In what form? We do not know – no one has reported back after she has crossed over. Many, like Brian, are pragmatic. They accept some degree of uncertainty, and are grateful for the extension of their mortal existence, but are not afraid of the next. I am quite prepared to share these marvelous insights with them, vicariously of course. Attempting to elicit a real NDE is too dangerous a game for me.

The Aging Brain

Arnold Tweed 

“What’s your name?” This question is the basic unit of social interaction, one of the first questions you learn in studying a new language. Asked of a new acquaintance this indicates interest and a desire to be better acquainted. Asked of a child it suggests that you respect the child as a person, as an equal. But when asked of someone you have known for fifty years, someone you have worked with, harvested with, played cards with and chatted with almost every day of your life – it has an entirely different significance. It is a sign of advanced dementia, and the enquirer recognizes that something is missing. To even ask the question suggests that there is a struggle for recognition, that the other face is familiar – someone he knew – but that crucial item of identity, the name, eludes him.

This is the most tragic stage of Alzheimer’s disease, when the sufferer is losing contact with the essential parts of his past, and realizes it is happening. He tries to preserve his shrinking world by filling in the missing pieces, but immediately loses them. This was Roy in 1972, on his last visit to his old community, where he had been born, gone to school, and farmed for fifty years. Where he had known everyone in the community since they had played together as children. But now he couldn’t recall the name of an old neighbour and close friend.

We had had a long talk on the drive out. For some time Roy had tried to deny his memory loss but now he was facing reality. He knew his memory was failing and he was afraid. How could he carry on every day activities, cope with finances, enjoy his family, if his memory were gone? How do you manage when your past is lost?

Roy was my father-in-law. He was small, wiry and quick – quick both of movement and wit. He did chin-ups with one arm, not just one but thirty in a minute. A farmer who had survived the dirty thirties, he was by necessity an inventor. When he needed a new implement he made it – one wet year, when the rains delayed harvest, he made a swath turner- so the swath would be exposed, dry quicker and be ready to combine sooner. He had a name for every animal on the farm and called each by name. When an issue of conduct rose he invented a cautionary metaphor. Gluttony, especially when new vegetables were so enticing in the spring, was discouraged by citing the tragic case of “the girl north of Crandall,” who ate so much she burst. And Roy was a good neighbour – when a neighbour needed help Roy was there.

On this final visit to his old community he knew that these parts of his life were slipping away. Within a shell of hesitancy and uncertainty was a person struggling to recognize the shadows of his fading world. Fortunately, he didn’t realize that even those shadows would soon disappear.

Alzheimer’s is the most tragic disease that afflicts mankind. It robs one of his past, of the memories that sustain us in old age. Without memory and recollections there can be no sense of identity, no concept of self. Without a past there is no future. The victim of Alzheimer’s is eventually restricted to the immediate present – the sensations of the moment and their gratification. Hunger is sated by eating, thirst by drinking, itch by scratching. Even the sensory present becomes narrower and narrower. Eventually eating and defecation become the only activities that give satisfaction, and, since all other sensory input has no meaning, sleep consumes the remainder of the day.

Is Alzheimer’s the inevitable price to be paid for a long life? Not necessarily, but certainly the risk increases after age 65 and about 25-35% of those who live beyond 80 will eventually be affected (See Figure I below). It is the most common of the “dementias”, a group of age related degenerative brain diseases (Alzheimer’s, Parkinson’s disease, Huntington’s, vascular dementia). They impair cognitive function by specific pathological processes, and, are different from the biological changes of aging, the changes that we call senescence. Senescence is a normal aging process whereas dementias have pathological causes. There may appear to be little difference between the senile and the demented, but the distinction is important.

Senescence affects all organs of the body, the brain included. But we all age differently and cognitive decline varies greatly from one person to another. Some of us will reach extreme age with virtually no sign of cognitive deterioration. A partial explanation for this variability and a cause for optimism is that the brain at all ages retains a remarkable adaptive ability called plasticity; some functions can shift from an overworked part to a healthier area and even from one side to the other. A younger brain shows more specificity (localization) of function while in an older brain it is more diffuse (de-differentiation). As a result, the functional map of an aged brain may bear little resemblance to that of a young brain.

Senescence is selective in another way, some cognitive functions are more susceptible than others.  Memory is the first casualty but memory loss is also selective; working memory and episodic memory are the first affected.

Working memory is the ability to retain a set of information (in short term memory) and use it to plan, organize and execute tasks. When working memory slows down, complicated tasks such as complex problem solving take longer and are less efficient. This may be hard to detect unless one deliberately challenges the higher cognitive functions, for example by playing chess or bridge. Often, our major frustration will be in keeping a set of new information intact. This is evident in everyday experiences – for example going to the garden shed, stopping on the way to rearrange the furniture on the deck, and arriving at the shed forgetting why I went.

Episodic memory is the recall of life experiences, the personal events of your life, linked to specific times and places. It is the important bits and pieces of your life stretching back to childhood. Senescence impairs the processes of forming (encoding), storing and retrieving episodic memories. Old, ingrained memories are better preserved though retrieving them may take longer. You may remember your first day at school but what did you have for breakfast this morning? Did anyone visit you yesterday? Who? Where did you put your keys? Of practical importance, episodic memory is the fundamental skill for independent living.

The good news is that we usually compensate well for the minor deficiencies, which mainly affect “fluid intelligence”. The concepts of “fluid intelligence” and “crystallized intelligence” were introduced by Dr. Raymond Cattell who was at the University of Illinois in the 1940s. Fluid intelligence is the ability to process new and novel information, to find creative solutions to problems, to “think on your feet.” Although these slow down, other types of memory, factual (semantic) and procedural memories are well preserved. Those are what Cattell called crystallized intelligence, our generalized, encyclopedic memory bank. We remain proficient at tasks that use this type of memory: cross-word puzzles and, hopefully, penning stories.

One special form of crystallized intelligence that is particularly well preserved is called procedural memory: walking, riding a bicycle, playing a musical instrument, reciting poetry.  One very famous case is a British musician, Clive Wearing (1938 – ), an accomplished chorus master who has complete amnesia due to a viral meningitis that destroyed critical parts of his brain (the hippocampus). His memory span is only a few seconds, his previous life is a blank slate. He lives in the 10 seconds of the present but recognizes his wife (though not her name), speaks fluently with an adequate vocabulary, and when given a baton and an orchestra can conduct flawlessly. His episodic memory is totally gone but his procedural memory is well preserved.

There is more good news. We might expect that older people would be less happy; they have plenty of reason to be. And, in fact, clinical depression is more common in the elderly, though more difficult to recognize and seldom treated. However, the “paradox” of aging is that on average older people are more satisfied, better adjusted, more stable emotionally and have better social relationships. Life gets better as we age; in fact life satisfaction scales peak at about age 65. The reasons for this are uncertain but it may be simply a matter of choice, older people have a shorter time horizon, they don’t have time to waste on negative thoughts.

The critical question is – can we slow the aging process? The Stanford Center on Longevity and the Max Planck Institute for Human Development in Berlin convened a conference of world experts in 2014 to examine the evidence. Their advice was to be wary of easy solutions – brain games – that are being promoted commercially. The main conclusion of the world’s best minds in this field was remarkably prosaic, “try to lead a physically active, intellectually challenged and socially engaged life.” How does that translate into everyday life? In most studies physically active means a half hour of walking a day. If you can’t walk ride a bicycle; if you can’t do either swim; if you can’t swim do aqua-aerobics. That is the easy part but how do we keep intellectually challenged after we retire? The key concept appears to be “productive – engagement”. These are activities in which you are intensely mentally involved: taking a university course, learning a new language, or a hobby such as wood-working. Dr. Denise Park in at the University of Texas at Dallas is a pioneer in these studies and has found that these activities improve the specific functions that deteriorate with aging – executive memory and episodic memory. The control group, assigned to “receptive (passive) – engagement” showed the effects of normal aging. Several well conducted experiments have now confirmed that the improvements are statistically significant.

The evidence is there – physical, mental and social stimulation may slow the aging process. Old folks benefit from doing the same things young people do, perhaps even something as banal as video games. They probably benefit least from watching TV and listening to retired entertainers. There is mounting support for a holistic approach to aging which emphasizes physical fitness, healthy eating, social stimulation, and cognitive exercises. Many of us can expect to stay physically active, mentally productive and socially involved into our eighth decade. Old age may actually become a time for new adventures and new experiences.

The outlook for those with Alzheimer’s and other degenerative brain diseases is less optimistic. Though the early cognitive dysfunctions are often similar to normal senescence, nothing is spared. Getting lost is often a critical sign. Roy went for a walk one day, just a block or two, and was found hours later a mile away and totally disoriented. This happened again, and again, and finally required his admission to a chronic care facility. He adapted well to his new environment; the locked ward seemed to give him a sense of security. His old home quickly became unfamiliar territory and he was always anxious to get back to the security of the care home. Within a few months he was totally dependent on their care.

The onset of Alzheimer’s dementia is often slow, but there are no definitive tests, the early diagnosis is usually tentative and the window of opportunity for planning and preparation may be short. Roy was in that window on his last visit to his home town; he understood that he was losing his grip on his world. That is the time for family, emotional and spiritual reconciliation – for divesting oneself of life’s burdens. There may even be a time in the future when end-of-life issues can be a personal choice, so that those at risk can plan for their terminal care and leave directives that will be honoured. Treatment in the later stages is solely supportive and our best hope lies in medical research (see Technical Notes).

There is another philosophical viewpoint we might consider. One of the most influential books of the 20thC was the Pulitzer Prize winner of 1974, The Denial of Death, written by Ernest Becker. His message is simple – “It is our mortality, specifically the knowledge that we are mortal, that gives meaning to our lives. Without that certainty our lives, like those of the immortal Greek Gods, would be trivial and pointless.” It may be a comfort, for some, to read Becker’s book.

How did Roy fare in the home? He went through all the stages of dementia – dependency and the progressive shrinking of his world – and eventually succumbed to pneumonia, ten years later. Our most famous Canadian physician, Sir William Osler, called pneumonia “the old man’s friend.” He was right; it is a gentle release from a life that has lost all meaning.

 

Suggested Reading (Cabeza, Nyberg et al. 2017):

The Aging Brain, 2013, by Thad A. Polk, Professor of Psychology, University of Michigan. Published by The Great Courses, 4840 Westfields Blvd., Chantilly, Virginia as a series of 24 lectures.

Cabeza, R., L. Nyberg and D. C. Park (2017). Cognitive neuroscience of aging : linking cognitive and cerebral aging. New York, NY, United States of America, Oxford University Press.

 

 

Figure I showing that the prevalence of dementia in the aging population approximately doubles every five years after age 65. From Google search: “Images for dementia statistics by age.” About 30-35% of the total population over age 85 will be expected to suffer some form of dementia – more than half will be due to AD and women will outnumber men 2:1.

 

Figure II showing that past age 80 women with dementia outnumber men, perhaps only because women live longer. From Google search: “Images for dementia statistics by age.”

 

Technical Notes:

The Cognitive Neuroscience of Aging (CNA) is a relatively new discipline, mainly research oriented, that combines elements of Cognitive Psychology and Clinical Neurology. A summary of current research and concepts can be found in a recent review (2017), Cognitive Neuroscience of Aging, edited by Roberto Cabeza, Lars Nyberg and Denise C. Park. Other sources are noted in the Suggested Reading list above.

Cognitive psychologists have developed a number of tests which can identify cognitive decline with aging and disease. Clinical neurology has provided the clinical tools and investigative techniques to assess the associated clinical deficits, changes in brain structure and corresponding changes in regional brain function. The most useful techniques have been the MRI and functional MRI (fMRI). Combined, they provide a comprehensive picture of the aging brain.

Two regions of the brain, the Hippocampus (HPC) and Pre-Frontal Cortex (PFC), play critical roles in the cognitive declines of both normal senescence and Alzheimer’s dementia (AD). Selective atrophy in these regions, and in certain white matter tracts, is an early feature of both conditions and the cognitive functions first impaired are also located in these regions.

The PFC is the frontal part of the human cerebral cortex. This is the newest part of the brain in evolutionary development and serves important higher cognitive functions including working memory and executive functions. Decline in these higher functions is probably multifactorial, due to both neuronal loss and impairment of processing speed. Slowing down in communications, a decline in processing speed, is common with aging and is probably also fundamental to other declines in performance.

Because episodic memory is our most important asset for independent living – and cognitive deficiencies in episodic memory are socially disabling – this discussion will emphasize the cognitive neuro-physiology of episodic memory. This is also a major interest of researchers in the CNA.

When psychologists discuss episodic memory, they define an episode as a conscious personal experience (an item) occurring at a specific time and place. In order to be a conscious experience an episode must activate areas of the cerebral cortex that serve sensory input, association and self-awareness. The resultant activation patterns can be registered on fMRI or PET scans and mapping such episodes is one of the fundamental preoccupations of Cognitive Neuroscience.  We may have hundreds of these episodes every day and, because they have no qualities that warrant remembering, most rapidly fade away. An episode does not become a memory unless hippocampal (HPC) structures are activated. Surgical ablations, done more than 50 years ago, showed conclusively that the HPC is essential for storage and retrieval of episodic memory. Current research, mainly in animal labs, is concentrating on how the HPC is organized to perform these tasks.

The first step in memory formation is the allocation process by which a memory item is allocated to a discrete set of neurons in the HPC. However, a single item of memory is of limited value and achieves more significance when viewed within the context of related items, a function that has been called associative memory. Think of the difference between a still photo and a video. Based on these assumptions scientists have focused their HPC research on the processes of allocation and the linkages that support associations between related items of memory.

Part of the answer may lie in a gene called CREB, which is essential for long term memory formation. The CREB proteins are transcription factors that regulate expression of other genes that are involved in forming and maintaining synapses between neurons. They are the molecular architects of synaptic connections linking networks of neurons.

The HPC (also called Ammon’s horn) acquired its strange name because of its resemblance to a sea-horse or goat’s horn. It is located in the medial temporal lobe, part of the telencephalon, and part of a complex group of interrelated structures in the medial temporal gyrus. The hippocampal complex, that is the hippocampus and related nuclei, is found in all mammals and serves several critical functions. One of the most basic is spatial mapping of physical surroundings. Watch a dog in a new garden running about the periphery, sniffing and exploring. He is forming a cognitive map in his hippocampus of his new domain, based on visual and olfactory representations. Our hippocampi retain the same functions and when we lose our spatial maps we lose our orientation and get lost, an early feature of AD.

Episodic memory is higher in the phylogenetic scale but probably utilizes variations of the same circuitry as spatial mapping. Current computational models hypothesize that these networks support two processes, pattern separation and pattern completion.  Pattern separation is the process whereby new associative information is quickly distinguished as distinct and separate from previously stored material, and is allocated to a discrete set of neurons with strong synaptic connections. Impairment of this function would impair memory formation and make it more vulnerable to distractions. Pattern completion is a process in which incomplete or degraded representations (clues) are completed by reference to stored memories. This facilitates retrieval since all memory clues are likely to be partial or degraded and impairment of this function would lead to slower and incomplete retrieval.

Parallel research with both animal and human subjects is beginning to provide evidence which supports these models and suggests a physiological framework for understanding episodic memory and its degradation in senescence and AD.

The allocate-to-link hypothesis is currently being investigated by Alcino J. Silva at the University of California, in L.A. Briefly, the hypothesis states that allocation, at least in the HPC, is not random – a memory will be selectively imprinted on neurons that are in a higher state of activation, that have expressed more CREB protein – and that set of neurons will remain in a higher state of activation for several hours. New and related episodes experienced within that time frame will be imprinted on a set of neurons that overlaps the previous set and these memories become linked. Recall of one memory, or a part of one, will recall the other. Research in several labs has confirmed these findings. Stimulation of neurons in one set provokes recall of the episode stored in the overlapping set.

A general theory of episodic memory might look like this. A poignant episodic memory (the stimulus) activates a receptive set of neurons in the hippocampus. That set is defined by its synaptic connections, which must be strengthened and maintained to retain the memory. The formation and maintenance of these synaptic connections is a least partly under genetic control, the CREB gene. We also know that that older animals (mice) have lower levels of CREB protein than do younger animals. Both pattern separation and pattern completion can be explained by synaptic connections and linkages. Weaker synaptic connections would reduce the cohesion within a set of neurons and impair pattern separation, and thus the ability to protect that set of neurons from distractions. At the same time it would also impair pattern completion by making it less likely that stimulation of neurons in one set would activate another or overlapping set.

This research is still at an early stage. Although there is no surety that manipulating the CREB gene or the proteins it encodes will have any significant effects on human cognition, this is certainly a potential goal for further investigation, particularly in the aged.

 

What day is it today?

Arnold Tweed 

My wife and I perform a silly little ritual every morning, usually while we’re still in bed with our first cups of coffee. We test each other, simple questions and answers, with roughly the same list of who, where, and when questions every day. We start with our name, date of birth and home address, then names of spouse and siblings. Then we go on to date and time: day of the week, date, month, and year. We finish with some general knowledge questions, for example the names of the current and previous prime ministers, and the capital city.

Are you beginning to recognize a pattern?  In medical jargon it is called orientation; it is the basic test of mental competence. If you have been in a hospital recently, as a patient, you will have had an orientation check. It is done by the first – and usually most junior – nurse and, if you are over sixty, it will have been done thoroughly.

Nurses take this very seriously; it is the determinant of whether they treat you as a person or as an object. And, if you are stressed and not prepared, it is very easy to fail – day and date are the most frequent pitfalls. If that has been your misfortune, you will have noted perhaps that the nurse looked at you long and thoughtfully, then wrote in your hospital chart. What she writes will, of course, be carefully phrased but will certainly express her doubts about your mental competence. From that point on her attitude towards you, and that of everyone else on the medical staff, will change perceptibly. They will be more condescending, will explain everything twice, and everything they do will be preceded by the interjection, “is that OK?” They will be extra careful that the seat belt of your wheel chair is secured and that the side-rails of you bed are locked. They will, with the very best intentions, begin to treat you as mentally incompetent.

Glenyce was recently almost caught in this trap, and perhaps this was the incentive for our present diligence. She was having vocal cord surgery because of hoarseness and was being interrogated with the routine pre-surgical checklist. Those questions are precise and always in the same order – name the type of surgery, the site and the side, right or left. Now, this generally makes good sense since, in the past, the most common surgical error of misidentification was operating on the wrong side: amputation of the wrong leg, arthroscopy of the wrong knee or excision of the wrong breast.

However, when you are hoarse, it is impossible to know which vocal cord is affected. When asked for the side of operation, Glenyce, not having prepared, had no ready answer. Knowing the consequences of a wrong answer, she almost panicked. The nurse, who was both very young and very serious, had begun her long, penetrating look and her unease was clearly mounting as the silence continued. How could she let this demented old lady, who couldn’t even remember which side her operation was to be, go on to the next station? She was just about to write this in the chart when I prompted Glenyce by surreptitiously scratching the right side of my neck. She quickly got the clue and interjected the correct answer just in time. It was a close call!

Now the rationale for this silly exercise should be obvious. Glenyce and I are preparing for the unforeseen emergency, for the sudden chest pain, the fall or the drunken driver that will throw us into the medical system with no opportunity to rehearse. If hospitalization is thrust upon us we intend to be prepared. But it is not just the irritation of the moment we wish to avoid. Once a diagnosis like “demented” or “mentally incompetent” is written in your file it sticks. From that day on you will receive the special treatment reserved for the aged and incompetent. Your medications will be counted for you and you will be watched while you swallow your pills. You may find a tag with your name and hospital ward pinned to your gown. You will be allowed out only in the care of a responsible adult, and you will be addressed with the tone of voice generally reserved for naughty children.

This is called “labelling” and it is one of the least appreciated aspects of the medical culture. Although a diagnosis, such as cancer, can also be a label, labelling is generally distinct from diagnosis. It not manifest so much by what you are called, but how you are treated, especially in large institutions. You may be labelled and treated as demented or incompetent without those words ever appearing in your medical file.

This has the ring of peevish annoyance, perhaps tinged with a bit of paranoia; is there any evidence for this accusation? There is. The seminal research was done almost fifty years ago by David Rosenhan (1920-2012), an American psychologist and Stanford University professor who was skeptical about the labels pinned on those with mental illness and the consequences of labelling. He was not alone, his doubts may have been stirred by the best-selling novel, One Flew Over the Cuckoo’s Nest (1962) by Ken Kesey, which had been adapted into a popular Broadway play and a movie. Rosenhan decided a scientifically valid test was required.

A report of the famous Rosenhan experiments was published in Science, issue 179, 1973 with the title, On being sane in insane places. It describes how Rosenhan and seven completely sane associates, ‘pseudopatients’, presented to different psychiatric hospitals with identical, factitious stories, claiming they had auditory hallucinations. All were admitted, but from the time of admission they acted perfectly normally and did not report any further hallucinations, or any other symptoms. They were all labelled with a psychiatric diagnosis (mainly schizophrenia), and given anti-psychotic drugs (which they flushed down the toilet). The average length of stay was 19 (7-52) days and they were discharged only after they acknowledged both their diagnosis (schizophrenia “in remission”) and their need for treatment. This was despite the fact they had been perfectly normal from the moment of admission. Even their suspicious behaviour ­– questioning other patients and taking notes – was cited as evidence of mental illness. The original diagnoses were never questioned or revised and quite likely remain on their records to this day.

These results, as expected, offended the prestigious psychiatric hospitals in the U.S. and one of the more prominent of these challenged Rosenhan to repeat the experiment, claiming its staff could ferret out his ‘pseudopatients’. During the following weeks 41 of 193 admissions to that hospital were identified by the staff as pseudopatients, as imposters, fakes. In fact, Rosenhan had sent none.

He concluded, publicly, that psychiatrists were unable to distinguish the sane from the insane. The Rosenhan experiments showed that labelling is often a reflection of the expectations of the examiner rather than the state of the patient. Moreover, once on your file, the label of mental illness becomes a lifelong stigma.

Although the Rosenhan study created a stir in psychiatric circles, that stir soon subsided. It took a medical novel, The House of God (1978), to popularize labelling and raise it to a literary art form: satirical, colorful and outrageous. The gomers, slurpers, LOLs and LOM, LOLs with NAD and other imaginative terms introduced in the novel, such as buffing and turfing, have become staples of the black humour of medicine. The House of God was written by Samuel Shem – the pseudonym of Stephen Bergman – who graduated from Harvard Medical School and interned at the Beth Israel Hospital in Boston, The House of God in the book. Although categorized as satirical fiction, it can also be read as an autobiographical account of his experiences as an interne. The belittling patient labels he popularized express the frustrations of the over-worked internes and residents assigned to their care. It was the first literary peek under the skirts of a major teaching hospital, and not a sympathetic peek.

Rosenhan saw medical labelling as an expediency which dehumanized patients and delimited the interactions of medical staff with them. Shem saw it as an outlet for the frustrations of the house staff. Both are affronts to patients’ dignity and obstacles to compassionate medical care. You will never hear a medical professional today refer to a patient as a “gomer.” That is not a claim that labelling has disappeared, just that the sort of labelling popularized by Shem is fictional and obnoxious. Medical labelling should be, and usually is, based on evidence, not prejudice. Part of the evidence is our responses to the questions that are integral to the medical interview.

Medical labelling, however, is only a small part of the picture. Descriptive and pejorative labelling are even broader and more complex. Think of persons labelled as sickly or neurotic. They may be sickly or neurotic only a small portion of the time but the label, and the social expectations implied by the label, cling to them always. They are marked as being different and are treated differently.

Pejorative labels are commonly applied to those on the margins of society. Terms like “drunkard,” “dirty old man,” or “bag lady” convey the picture. The sociological theory of labelling, introduced in the 1960s, postulates that the label determines the person rather than describes him. The drunkard drinks, the bully bullies and the dull-witted fails – because that is what is expected of them. They tend to become the person of the label, and their actions are shaped by society’s expectations. Labelling theory is often invoked to explain anti-social behaviour, especially by the frustrated mothers of rebellious teenagers. Fortunately, most rebellious teenagers eventually tire of role playing and mature into adults. Other pejorative labels are harder to shake.

The aged, particularly the aging male, have been singled out for special attention. History, literature and bawdy humor have mocked old men with labels that are particularly objectionable and disparaging – doddery, rheumy, old codger, gaffer, old goat, old geezer or old lecher. Older women appear to be treated more kindly.

These labels carry a hidden risk that must be carefully avoided. There is a seductive temptation to imitate juvenile males and adopt the role endorsed by the label. Although juveniles will eventually mature and grow out of role playing, there is no such hope for the older male. We must, therefore, deliberately cultivate the labels we prefer within the boundaries of social acceptability. Do you have favourites? I do. Why not cultivate a benign but plausible label that has personal wearability? Sport a bow tie, drive an old Mini Cooper sports car, and eschew email. That will certainly earn you a label, probably “eccentric” not “sporty,” but it is certainly preferable to being called an “old stodge” or an “old curmudgeon” or any of the other labels listed earlier.

Those are not my personal props of course, but to reveal them is to blow your cover. Mine work for me and I don’t mind being called absent-minded or even a little peculiar. Most of my friends expect me to act a bit odd and are not upset if I scratch in public or forget their names. Labelling of that sort can be used to your advantage, to cover-up your real idiosyncrasies, but I also advise an orientation check every morning.

Unwelcome medical labels confer few benefits and the label ‘demented’ is among the least desirable, particularly if you are certain you are not. We cannot avoid interactions with hospitals so we must prepare. Anticipate the probing questions that will be asked and consider the answers you will give. It is worth investing a few minutes of time each morning rehearsing.

 

Glossary of Terms from The House of God

 

Gomer (fem. Gomere): Get Out of My Emergency Room. A pejorative label applied to old and demented patients, “A human being who has lost – often through age – what goes into being a human being.” (The Fat Man)

Slurper: A term applied to anyone in the medical hierarchy of the House of God above the level of junior resident, which was the level of The Fat Man and Jo. It implies that promotion is achieved by licking one’s way up.

LOL and LOM: Little Old Lady and Little Old Man.

LOL with NAD: Little Old lady in No Apparent Distress.

Turf: To transfer a patient to another service or out of hospital. To get rid of an unwanted patient.

Buff: To polish or to make look good, a preparatory step for turfing.

House Staff: Internes and Residents.

 

Munchausen’s syndrome

Arnold Tweed

Psychiatry was my last rotation as a junior interne. I had completed all the required rotations in medicine, surgery, pediatrics, and obstetrics and considered myself, with justification, a savvy and battle hardened young doctor, within a month of receiving my certificate to practice.

I had seen it all: pathos, mayhem and violence, and self-mutilation. I had witnessed nobility and courage in some patients and helpless defeat in others. I was ready for the world of medicine, not just the clinical challenges but the challenge of reading patients – their needs, their fears, their intentions and above all, what they were hiding.

A month of psychiatry was almost like ending my internship with a vacation. Since I was the only interne I would be on-call 24/7, but the case load would be light and emergencies infrequent. Unlike my previous services, a week-end on call would be a week-end of loafing at home.

The first call from emergency came about 10 pm on my first Friday. It was a common week-end incident, ‘attempted suicide’. The patient, Reginald R., had been brought to the ER by the police. Their story was simple and brief. The man in their custody had been standing on Portage Avenue, at the bus stop in front of the Eaton Centre, chatting amicably with one of Winnipeg’s finest when he suddenly threw himself in front of a bus approaching the stop.

The policeman, both quick witted and nimble, pulled him back but our patient fought him off and tried to scramble under the wheels of the bus, now stopped and loading late night passengers. He ignored the advice freely offered by both the officer and the commuters – who only wanted to get home – and loudly declared his right to end his life.

Since he had to be physically extricated from under the bus, which was already behind schedule, the policeman was stuck with him. And, since it was also near the end of the officer’s shift, he probably made a quality-of-life decision – quality of his life that is, certainly not mine. If he took Reggie to the ER of the Winnipeg General Hospital he could turn him over to the constable on duty, and go home; if he charged Reggie and locked him up he would be stuck with two or three hours of paper work.

Such were the life-or-death decisions that led to my summons to the ER at 10:00 on a Friday night to admit an attempted suicide. I wasn’t particularly distressed; it was my only call of the evening and attempted suicide was a legitimate admission. Once we got Reggie to the ward it took a rather large dose of Valium to sedate him but he soon went quietly to sleep and I quickly followed suit.

I had the whole week-end to sort Reggie out, my first real psychiatric patient. Admittedly, I had some reservations that psychiatry was a real medical specialty but I wanted to make a good impression for my last month so I did a thorough medical examination as well as a psychiatric history. Reggie was a small, middle aged man of no particular distinction. His manner was diffident, almost apologetic, his voice soft and pleading, and he paused after each statement as if judging its effect. He had the remarkable knack of watching you without staring. The only notable feature of his physical examination were his abdominal scars, evidence of multiple surgical attempts to explore his innards, for reasons I could not immediately discover.

Reggie was more than willing to talk, he was downright eager. He told me about his abusive father, his thankless employer, his cheating wife and his difficult childhood. He had been brought up in a poor family with a mother who did house-cleaning, an older sister who went out every evening (he didn’t know where) dressed mainly in mascara and hot pants, and a father who did odd jobs and drank. Most evenings his father would beat his mother until she surrendered her day’s pay, and beat Reggie even more when he tried to defend her.

Reggie left home at age 16, after his mother died tragically, and joined the air force at the outbreak of WWII. During the war he was a tail gunner in Lancaster bombers and had many harrowing experiences, which he would be happy to relate later. After demobilization, he worked his way up from shipping clerk to dispatcher in a large trucking firm. Life was going well until he developed serious medical problems. He had no medical or disability insurance but his doctor insisted he have a laparotomy (surgical intra-abdominal exploration) to diagnose his pain. After the operation he was worse and his misery was compounded – no job, no savings, no severance pay, no benefits.

That was when he discovered his wife was cheating with his best friend. One afternoon, exhausted from his fruitless search for work – “any job,” as he put it – he came home early and found his wife and friend in bed together. She was unapologetic, berating Reggie for being sick and out of work. He left and had been trying to get himself straightened out ever since but struggled with his depression. He had found very few people who were willing to help him and medical people had proven particularly disappointing.

He had been diagnosed, he informed me, with gastric epilepsy and the conspicuous scars on his abdomen were evidence of fruitless surgical attempts to relieve his agony. When the attacks came, the pain was excruciating, only tempered by large doses of Demerol. But some doctors – and here he became bitter and resentful – rejected him just as his wife had done. They treated his attacks with placebos, injections of normal saline. He could tell the difference immediately and could hardly believe that trained doctors and nurses, who had taken the Hippocratic oath, would let another human suffer as he suffered. He hoped that I was not of that ilk.

A half-hour after I left the ward I had a call from the nurse in charge. Reggie was having one of his seizures, clutching his abdomen in agony, crying for help. I immediately went back to examine him and found him, as described, writhing with pain. When I examined his abdomen he complained of excruciating tenderness wherever I probed, but he didn’t have the rigidity, guarding and lack of bowel sounds of an acute abdominal crisis.

He hoped I would not leave him in unbearable pain for the whole night as others had done. My first inclination was to get a second opinion, a surgical consult, but the surgical residents were busy exploring a knife wound and then had a perforated appendix to deal with before they could even consider my patient. I gave Reggie intravenous Demerol and only after an remarkably large dose did he relax, and with a satisfied smile he fell asleep. There were two more such episodes between then and Monday morning but adequate doses of Valium and Demerol ensured that both of us got some sleep.

My psychiatric consultant was a hardened veteran of encounters with the inner-city residents. After my detailed presentation, it took him less than 15 minutes to assess Mr. Reginald R. His instructions were terse, “discharge him with no medications.” I was amazed at his penetrating perception, but he had some information he neglected to share with me. Last week, before I joined the service, a city wide psychiatric conference had discussed a case with many of the features exhibited by Reggie. Perhaps it was the same patient. It was labelled “Munchausen’s syndrome” and all psychiatrists were cautioned to be wary.

I went back, rather chagrined, to break the bad news to Reggie. He had already packed his meager belongings and left. He saw it coming, probably not for the first time!

Munchausen’s syndrome is one of the oddities of human nature and its etymology has colorful origins. The first and still the best description of the condition was by a British physician, Dr. Richard Asher, who in an article published in The Lancet in 1951 described patients who “Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly, the syndrome is respectfully dedicated to the baron, and named after him.” (Asher 1951) The official label now is Factitious Disorders (DSM-5), a rather bland descriptor, and I prefer the old term.

The famous Baron Munchausen that Asher refers to is a fictional character invented by an 18th Century German author, Rudolph Erich Raspe.  In Raspe’s accounts the Baron is a braggart soldier who entertains his friends with implausible stories. But legend holds that he was a real person, a German aristocrat who served with the Russians during the Russo-Austro-Turkish War of 1735-39 and later became a raconteur of some notoriety. He is still remembered in parts of Europe though his popularity in North America has faded.

Munchausen’s patients are ingenious in concocting factitious symptoms. They baffle their caretakers in numerous ways: by contaminating lab tests (putting sugar in urine samples for example), by self-inflicted injury, often very difficult to distinguish from real injury, by injection of fecal material into the skin to produce abscesses, by tampering with surgical incisions, by insertion of foreign bodies in various body orifices (including the urethra), by ingestion of drugs or chemicals and much more.

The syndrome is not widely reported in the medical literature; it does not excite young doctors who are trying to bolster their academic credentials. The largest review – 455 cases – was compiled by GP Yates and MD Feldman in 2016. (Yates and Feldman 2016) They found that about two-thirds of reported cases were females (average age 34 years) and many had a psychiatric history. Unfortunately, most reports are simply descriptive and there is little insight into their bizarre behavior.

Munchausen’s syndrome is a perplexing mental disorder in which the patient craves medical attention (even surgery), not just material gain. Their needs are complex and probably include dependency issues and drug addiction. Munchausen’s can be confused with malingering, but malingering stems from different motivation; malingerers feign illness for material gain, for example to avoid work or military service. Munchausen’s and malingering are both different from hypochondria. A hypochondriac truly believes that she – most are women –  has a serious or even fatal disease and no amount of reassurance or negative tests will convince her otherwise.

To make matters even more complicated there is also a Munchausen by proxy syndrome in which the symptoms are feigned or induced in a child, often by the child’s mother.  This gets attention since the victims are young and vulnerable and likely to become adult Munchausen’s.

It is not surprising that Munchausen patients elicit little sympathy. They are viewed as malingerers and their caregivers are offended by their deceptive and manipulative behaviour. There is no charitable foundation canvassing on behalf of Munchausen’s patients, no trust to fund research into its cause.

No effective treatment has been reported and, in any case, they show no interest in being cured. They are elusive, adept at deceiving young doctors and nurses and at vanishing as soon as their deceptions are revealed. They are the phantoms that haunt Emergency Rooms, lurking in the shadows at the fringes of society and disappearing as soon as the light is shone on them. Like the Baron Munchausen of old, they are itinerant story tellers, playing to a credulous audience and attempting to keep one step ahead of discovery.

 

 

Asher, R. (1951). “Munchausen’s syndrome.” Lancet 1(6650): 339-341.

Yates, G. P. and M. D. Feldman (2016). “Factitious disorder: a systematic review of 455 cases in the professional literature.” General hospital psychiatry 41: 20-28.