Wednesday, January 1, 2014

Man of Steel


Hello 2014! This blog post probably makes more sense if you have seen Man of Steel. Seriously, spend $1.50 at redbox. It’s awesome. Though perhaps ethically disappointing

I know it has been a long time. Suffice it to say that between some unexpected illnesses and deaths in the extended family, along with the normal life of a family with two working parents and two very active little girls, there was simply no extra time or energy for a little while. There was also a little stutter in my sense of purpose, trying to figure out what it is I am trying to do here. There is a lot more attention from my fellow psychiatrists (the president of the APA follows me on twitter, so all the sudden I feel a little awkward sharing my 140 character opinions and links on the Hunger Games). Far more importantly, I’ve been honored to be selected for a three hour symposium on Evolutionary Psychiatry at the next APA annual meeting in New York City, which is the major meeting of psychiatrists in North America, if not the world.  It’s all very academic and serious. 

Yet the underpinnings of what I am trying to say (and, in this blogosphere, trying to pick out the truth) are so simple it often feels as if there is nothing left. Sleep well. Eat well. Take a break. Be merry-ish. I am not temperamentally designed for ambivalence (except as an appropriate therapy tool), but after three and a half years of blogging the basics are settled, and the tougher subtleties come to the fore. The blog is coming out of infancy and becoming self-aware. A separate consciouness dogging me, and mocking, sometimes. Is there no way to make a difference without being outrageous and unconscionable?

There is a community now, of doctors and people looking for common sense and an active role in their own care. Yet the publicity is centered on the straw-man paleo critics and the ridiculous purveyors of “paleo” brownies and doughnuts. I do see a use for these on some level and I don’t begrudge anyone the right to make a living by selling grain-free garbage, just not with that smarmy stamp of “health” across the top. It’s no better than the American Heart Association approval across the top of cheerios or whatever stupid processed cereal product they decide to endorse (shoot, even the AHA is ambivalent about the grocery store, as I can’t get their grocery store heart check products list to even load at the moment).

 It’s like Christopher Nolan took over my blog and replaced the shining optimism of a summer blockbuster with the dark semi-antihero superhero (spoiler!) who breaks General Zod’s neck in front of the sobbing families in Grand Central Station or the Metropolis equivalent. Yet life is really positive and wonderful, and the kids are doing well, and business is booming.

The ultimate child-like medical journal (no grumpy, scene-stealing, genetically engineered to be two-dimentional Krytponian General Zods allowed) is Medical Hypothesis. The staid and serious need not apply. No question that the glorious and insane ideas unleashed there could spark a revolution in medical treatment. The next generation is inspired, unplanned, and is blessed with the looks of Henry Cavill (he is training at Gym Jones for the MOS sequel, can you confirm this, Dallas?). Maybe. Or maybe it’s all an optimistic waste of time or craziness. You never know until the battle to the death that makes it all clear at the end of the summer blockbuster.  Victoria Prince (with her shiny new MD and PhD in addition to her native awesomeness, not unlike like Natalie Portman in Thor) sent me an article from there about OCD and the gut microbiome.

OCD I’ve always considered to be one of the more “organic” of mental disorders. More neurology, less psychology. Let’s not confuse it with obsessive compulsive tendencies that have led many a med student to success. No, OCD is a heart-breaking disorder, where people get stuck with unwelcome, repetitive, ego-dystonic thoughts and engage in uncomfortable compulsions to relieve the anxiety of those thoughts. Typical thoughts include pedophilia in a teacher who would never dream of harming students, or killing your own children, or stealing, or running over someone, or being contaminated by germs. (Hoarding is thought of as a variant of OCD, but is more responsive to treatments such as stimulants, which typically make OCD worse). Worsening OCD symptoms tend to be caused by pregnancy (even typical post-partum depression symptoms are OCD in nature, worries about the harming the baby, germophobia, etc.) and other stressful life events. It’s horrible but, in my experience, typically amenable to the standard treatment, therapy with an OCD specialist and high doses of SSRIs. Hardly paleo but neither is an appendectomy. Seriously, I’ve had patients who have led shadow lives for decades, bothered by these intrusive thoughts, who tried therapy after therapy, finally convinced to take an appropriate dose of medication who are suddenly free of the obsessions, the compulsions, and the constant mental torture. It’s an awakening. Sol to the native-born Kryptonian. Stretched the metaphor too far? Sorry, you are reading the wrong blog.

But I’ve been interested in the microbiome for a long time. 90% of our personhood are these “other” cells who inhabit us. They communicate with our brain, serve as a major part of our immunity, and regulate our immune response. Right up until the 20th century (more specifically mostly before 1975) we co-evolved with parasites, certain commensal bacterial, and pseudocommensals. The major autoimmune diseases, such as multiple sclerosis, rheumatoid arthritis, asthma, etc. have increased in incidence and prevalence in the last thirty years (though peaking, in some instances, around 2000, prior to more aggressive anti-autoimmune medical care instituted early). OCD has long been considered a variant of an autoimmune disease (while most of my patients were affected in childhood, I do have a few who became symptomatic in adulthood after infection with lyme disease, herpes, or other neurologic pathogen, plausibly leading to an autoimmune attack on the brain causing chronic OCD symptoms.)

So what does Medical Hypothesis have to say about all this speculation? Both dietary and emotional stress are known to affect the microbial population. And the PANDAS associated with OCD might not be the problem…perhaps it is the antibiotics given to treat the strep infection? Let’s not forget that before antibiotics, people died right and left of scarlet fever and all sorts of bad things. Henry Cavill also struggles with throwing the baby out with the bathwater. Do I reveal myself and save the school bus full of children? [SPOILER] Does Kevin Costner really want me to let those children drown? Good thing the tornado takes away his crazy moral equivalency…

The Medical Hypothesis article calls for the trials of probiotics that we all deserve, except that everyone knows the only hard core way to permanently affect the gut microbiome is via helminth therapy (yes, introducing parasitic worms) or fecal transplant. If we are going to be radical, let’s go radical in a scientific and controlled and meaningful way.

I’m impatient sometimes. And no one wants to wait for everyone to wear blue-blocking glasses, get some general daily activity in already, and save the magic paleo cookies for a few special occasions a year. People want sensibility, convenience, beauty, and fresh air. A glorious man in Antarctica who can fly with his red cape in the light of our young sun. Coconut milk. Roast beast. Fermentation. They want a grumpy, two-dimensional villain, like Zod, or Carbsane, or the Medical Establishment, or the flu vaccine.

I get so many emails that break my heart. Can you help me, I’m sick, my relative is sick.

I have no magic elixirs. I am no Henry Cavill. I can barely keep myself operating sometimes with all the souls currently assigned to my watch. I couldn’t save my young cousin from sarcoma. I can’t save anyone. You have to save yourself.


19 comments:

  1. Thinking of the reality-testing problems with OCD, do you feel that the disorder as a whole may be on a thought disorder type spectrum (like the diseases that start with "schiz") or do you think that is only true for severe cases? I'm wondering if the research on the schiz's might be applicable here.

    Also, any thoughts for treatment when clients are not responding to high dose SSRI's and are not tolerating SGA's?

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    1. It can feel very similar to someone who is delusional, in particular. So far as med failures, I've heard all sorts of experimental things (don't quote me on these). Lamotrigine, namenda, NAC…or the FGAs, stelazine or perphenazine for example. It's also really important paritcularly in the treatment failure for a trial of OCD desensitization treatment. We are lucky to have several OCD clinics within an hour of my practice. There's also cingulotomy which can be extremely effective in intractable cases and is done at MGH (http://neurosurgery.mgh.harvard.edu/functional/cingulot.htm)

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    2. Thanks for your reply! I've had good luck with NAC but I have a couple of cases where nothing is working and there aren't any specialty clinics nearby. Lamictal is something I definitely haven't tried yet, maybe it will help. :)

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  2. Welcome back, I've missed you. Interesting stuff. Keep up the good work. You have helped me , so thank you, Emily

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  3. Perhaps OCD is caused by a nutritional deficiency?

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271502/

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    1. I've seen "new onset" OCD in a 70 year old woman who turned out to be incredibly anemic. (OCD doesn't tend to pop up out of the blue in 70 year olds so we new it was secondary to something).

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  4. So sorry to hear of the unexpected illness and losses in your family. We are all so fragile. I can't find good enough words, but it reminds of what is most precious in life.

    Regarding treatment resistant OCD, do you have thoughts on the positive outcome of some "best responders" in Columbia Psychiatry's studies of minocycline? It seems complicated, as articles on minocycline discuss many issues, e.g. antibiotic properties, microglial activation, neuroprotection, etc.

    I also really appreciate the distinction you make between OC tendencies that may be adaptive in many ways and debilitating OCD. I find that it can be especially confusing when the thought content is more "typical?," e.g. work needs to be checked (but way too many times over), reading and rereading a sentence, each time feeling comprehension is just not good enough. Taken far enough, these tendencies can wreak havoc at school or work. The same might be said of problems making decisions or, in the area of hoarding, obsessions with doing the right thing by the environment, thrift, sentiment, etc. One thing that strikes me is knowing people who are absolutely miserable (vs. proud of the lives they live) with each and every one of these tendencies. Perfectionism, maybe, but with the opposite feel to stereotypical OCPD. These people consider themselves incompetent while admiring the competence of others.

    I am not very familiar with discussions of paleo, and I have a sincere question. I sometimes read that it is good for us to eat the way certain ancestors ate. I really, really would like to know what is best to eat (not that I don't have plenty of will power issues : ) ). It's just that, if I'm trying to make a best guess about how to eat based on ancestors, I need to know how to guess well about how things may have evolved (or not) since the time of those ancestors. This savvy is missing for me. In answering my blog question about milk, Paul Whiteley passed on a link suggesting that humans can be "pretty adaptable creatures ... http://news.nationalgeographic.co.uk/news/2007/02/070226-europe-milk.html" I myself drink almond milk for reasons that are mostly not health related. Anyway, I sincerely would like to understand more about how to guess well as to whether and how any humans may have adapted from particular ancestors with regard to certain diet issues and if so, how likely it is that adaptations may have happened in a particular individual. Thank you so much for your blog!

    P.S. Link to Paul Whiteley's blog entry with milk discussion in comments section: http://questioning-answers.blogspot.com/2013/09/autism-and-gfcf-diet-scanbrit-episode-2.html
    Please excuse if not useful, but I don't want to misrepresent, so I think I should at least link to the context.

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  5. This morning, I had an OCD-ish "attack" that I never would have defined as such until about three minutes ago, after reading this blog post! I've spent the afternoon doing a Web Searche in my Quest to Understand What To Do....

    Briefly: I was vegetarian (and a chef and cooking teacher, so my meals were all-homemade and whole-grain and Careful) until the age of thirty, when my son's ASD-, anorexic, and OCD-style symptoms were getting out of control. He was 6; we started the "Gut and Psychology Syndrome" diet the day after I found out about it.

    Fast-forward through the Great Trauma that came along with our overnight switch to carnivory, combined with the monumental behavioral challenges that attended our main task: getting our super-crazy-amazingly-self-limiting son to eat...

    He's now ten, and he EATS. Everything I put in front of him, even vegetables and ferments and raw liver (grudgingly) and cartilaginous- and fatty-meats.

    For the first two years on GAPS (super nutrient-dense, low-sugar version). my own depression and PMS-type symptoms were markedly improved, despite the super stress of dealing with my son, not to mention All The Cooking. Then...I got pregnant with our third child, and became so severely depressed (and started getting panic attacks, repetitive, horribly-self-defeating thoughts (and I really am a fairly decent person with many talents! And used to be able to keep perspective on that)), that we moved in with my parents for nearly three months.

    We finally came home, two months before my daughter was born, in June 2012. She had severe feeding issues (ironically?), tongue-tie, lip-tie, and developmental delays that we have yet to unravel fully. I pumped breastmilk for over a year, and even though she still breastfeeds, she has never been able to do so effectively enough to get much milk. And I cannot figure out why she has terrible eczema, even when I eliminate dairy and eggs from her diet...

    I had the hubris to think that this time, my offspring would be perfect, due to my perfect diet!

    I have very little hubris left. Anyway, although I am much more stable than I was, I still struggle mightily with depressive episodes, anxiety, and - at least I think, after reading this post - OCD-type manifestations. So many people have recommended drugs, and sometimes I feel so tortured that I think I should just try it.

    Except I keep thinking (maybe delusionally?) that if I could figure out the right tweak to my diet, to my metabolism, then maybe I could feel better even without drugs. Willpower is not really the problem - mostly, it's my lack of conviction, and trust, that I've discovered anything new that's worth trying. It took a LOT to change my diet from vegetarianism, and while I think our current GAPS-type diet is really hugely on the right track, I am sure that it is not perfect.

    I've recently been reading some of Paul Jaminet's thoughts regarding glucose and the brain, and ways to induce ketosis without starvation, while also eating more carbs (i.e. starches) than I usually do. I wonder if this is a good tack to try...

    ...and I wonder whether you have thoughts on this, on the fine-tuning of diet, as one progresses on ones healing journey.

    I know you must be super busy, and I really appreciate you reading this, even if you don't have a chance to reply. But if you do think you have helpful suggestions, I would so love to hear them, and I'd be willing to pay you for a phone consultation if you think you could help.

    Regards,
    Sarabeth Matilsky
    www.lifeisapalindrome.com

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  6. Hi Emily,
    This is slightly off-topic for this particular post, but have you seen any of the work by Michael Berk? (I think you probably did and I just wasn't paying attention to study authors, but just in case!) He collaborated a bit with Michael Maes, and a good chunk of his research is along the same lines of diet, exercise, supplements, etc. for depression, bipolar, schizophrenia, OCD, autism. He seems to have done lots with NAC. You likely covered some of his stuff already, but here's a link to his publications: http://www.deakin.edu.au/research/admin/pubs/reports/database/dynamic/output/person/person.php?person_code=berkxm&cat_code=

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  7. My PANS/PANDAS daughter's intense anxiety abated considerably with the GABA-producing probiotic Bifidobacterium infantis 35624 (sold as Align in the U.S.). Her tics and ADHD are still present, but they seem to be helped somewhat by fresh-squeezed grapefruit juice. Sounds flaky, but the naringenin does seem to help intestinal permeability. PubMed tells you why. Also, google the videos of Alessio Fasano, MD. He used to be at Harvard-MGH and is convinced gut permeability has a major role in autoimmune diseases such as OCD, schizophrenia, etc.

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  8. Do you think a lot of people with recurrent strep have their tonsils removed? Could this somehow be a factor?

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  9. "Is there no way to make a difference without being outrageous and unconscionable?"

    I hope so, and hope not. But, if there is, please let me know and I'll take it under consideration.

    ;)

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  10. "But I’ve been interested in the microbiome for a long time."

    YGG. Especially in your profession. You can help millions, I'm thoroughly convinced. Not only from my own experience from calmness, don't sweat it, to vivid dreams and sleep that's like you really slept, and I could go on.

    All from a solid focus on feeding the other 90% of who I thought I was over about 8 months, now.

    This will eventually prove materialists right over moral philosophers.

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  11. Given how Lithium and other antipsychotics affect arachidonic acid turnover, etc., do you think taking an antipsychotic would alter RBC AA and other things on an omega panel?

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  12. Dear Emily Deans,

    You are right. We must all save ourselves. But we do not have to do this alone.

    Your blog, along with so many others, such as Stephan's, Nikoley's, Kresser's, Wolf's, Harris', Mat Laonde's (if he friggin had one), etc. have helped to save many people by putting this valuable information out there for those interested in saving themselves to read and learn from (for free!). I personally have healed a broken leg, my mother (who has Parksinson's) is doing great on a ketogenic diet, my brother has lost 15 kg and stopped habitually vomiting every morning and my fiance's constipation and acne have cleared up since following your guidelines. Superman did not save them, western medicine did not save them, a little initiative, willingness to experiment and the sound information you and others provide with a gluten-free breadcrumb trail of scientific references saved them.

    It breaks my heart to think you are doing all this good but not feeling the reward, not feeling like you have helped people. You do help save people. There is a face behind this text and it is smiling and healthy. There is no General Zod in my world, but there is celiac disease, depression, neurodegenerative diseases, etc. all around me. Fuck Superman! I need a community of educated, philanthropic people to help me provide me with and make sense of the scientific literature.

    You are a valuable part of a community! It makes me want to cry to think that someone with such a good heart, such as yours, is out there researching and putting information out there for the good of others (for free!) and that you do not get the positive feedback you deserve.

    It seems the blogosphere is a double-edged sword. Your blog, as well as others, is a tool that helps so many people all over the world. I live in Taiwan for goodness sake! But you don't get to see the fruits of your labor. You may never see my mother smile, free from her tremor or see me sprint on a healed leg or my girlfriend's radiant skin (or smell her stinky bathroom in the morning!) but every time I do, I think of you and all the other true heroes out there on the internet that are good scientists, doing good, free work for the global community. I'm sure you have many other things you could do with your time.

    This website, and others like it, truly are the promise of the internet come true. This is free information, that is easy to access and makes everyone's life better. That is what the internet was intended for (well that and strange pornography and youtube videos of people falling down, but I digress).

    It is no small task that you and others have undertaken. You have helped to change my life, and all those I come into contact with. Please accept this humble thank you on behalf of myself and all those anonymous lurkers who have been helped by reading your blog, and all the other great bogs. I am sure they felt gratitude when reading your blog, they just forget to say it. I guess reading so many blogs, it's easy to forget that there is a person behind that text who is just genuinely trying to help.

    And I also want you to know that you have inspired me to try to be a better, more magnanimous person. I will try to share more and be selfish less. You have also inspired me to go back to graduate school and continue studying psychology. I love the evolutionary perspective you bring to the table.

    I would like to see some blogs on contemplative practices, shamanism, and psychoactive plants like ayahuasca in relation to mental health issues. I wonder how you feel this could be employed in a clinical setting. Thanks to scientists like Richard Davidson contemplative psychotherapy and contemplative neuroscience is really taking off.

    And please if you talk to Kurt Harris, tell him to start blogging again. The last interview I heard with him and Jimmy Moore was in 2011! And he was saying prebiotics and probiotics were a fad. I would love to hear what you and he think about that now.

    Keep up all the good work. We need you.

    Thank you.

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    1. I'm glad I have been helpful. And I haven't lost faith…just finding myself more inspired by the one on one again of clinical practice rather than some of these bigger questions.

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  13. i have tried NAC one-month-dose, but i didnt feel anything. so interesting, when i have fever, my ocd symtomps decrease. i dont know y... but i always waiting for influ :) is this an autoimmune disorder? i hate this, and i wanna do everything to treatment myself! 26 y male

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  14. Dear Emily,

    I first would like to say I have enjoyed all your eloquent, always thought-provoking and enlightening posts (here as well as in Psychology Today), and I feel fortunate to have stumbled across your twitter account about a year and half ago.

    I have a bit of a random question, and I didn't want to email it, because it would clutter your inbox, and I thought if I post it here, and maybe someday someone else with a similar question sees my question, and maybe also your answer, then it will save both you and that person time.

    I have been worrying about a problem with what I think could be related to gut bacterial imbalance. I was reading Bulletproof Exec's information on his website, but although it provided good insights, I thought I would try to find more background info. As I know you have sometimes tweeted about this topic, I thought I would try a search term here, but I couldn't find a search engine. I wonder if you could recommend any online source of info you trust that would be a good start for me to research this.

    I realize it's also a good idea to see a doctor, but I have very little spare time for it, especially as my (student) health insurance has changed, and I don't know what all is actually covered, or have time to read all the fine print. (Also, the last time I visited a doctor, she just said I should avoid eating any greasy or high fat food, and didn't seem to think any more of it.)

    There is no rush at all to answer this, and I appreciate any input you might offer.

    Best,

    r.r. (or t.t.)

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