Monday, March 2, 2015

Lithium and Flamingo: Atacama Survival!

The Cockroach Catcher has been rather quiet as he was in one of the world's more remote areas: Atacama Desert of Chile.


As one of the firm advocates of Lithium, he thought he needed to be where much of the world's Lithium could be cheaply produced.

As a lover of wild life he soon finds himself in a difficult position especially as much of the Lithium would be used in batteries for cars such as the $100,000 plus Tesla and your iPhones and Tablets.



Chile could produce lithium cheaply by using water and in a desert where the water is scarce this creates a problem: especially for the Flamingos. A third of the lake water is now used for extracting the Lithium.



All photos © Am Ang Zhang 2015

There is a view that the water will run out and with that the Flamingos will perish. Just a worry especially as The Cockroach Catcher was not sure if any Lithium will be left for Manic Depressives (Sorry: Bipolars!)



A reprint:

Chile: Salar de Atacama & Bipolar Disorder.

Santiago, Chile was the starting point of our recent cruise round Cape Horn. We had a wonderful guide who took us from Santiago city to the Valparaiso port, where we boarded our cruise liner. She was infectiously enthusiastic. She told us that apart from copper, agricultural products and wine, Chile produced something that was very important for her brother.  He suffers from Trastorno Afectivo Bipolar (Bipolar Disorder) and Chile is the world’s largest producer of lithium.


Some of the world’s most important deserts are around the Tropics of Cancer and Capricorn and here in Chile the desert called Salar de Atacama is no exception. 
Our guide told us that as the snow melts in the Andes the water went underground and dissolves the lithium salt to form lithium brine. It is pumped to the surface where the sun did the rest of the work in evaporating the water content. Lithium could then be extracted from the salt. According to Forbes, the solar energy keeps lithium extraction costs to an estimated $1,260 per ton of lithium carbonate. It sells that ton for up to $12,000.


From the NASA website

The Salar de Atacama in Chile is an enclosed basin with no drainage outlets. (Salar is Spanish for “salt flat.”) The salar is located in the southern half of the Atacama Desert; with no historical or current records of rainfall in some parts of this desert, it is considered to be one of the driest places on Earth.

The brines are pumped to the surface through a network of wells and into large, shallow evaporation ponds; three such evaporation facilities are visible in the center of the image. Color variations in the ponds are due to varying amounts of salts relative to water. The dry and windy climate enhances evaporation of the water, leaving concentrated salts behind for extraction of the lithium.

There is increased industrial use of lithium.  Major car manufacturers are switching to lithium batteries which are much lighter than conventional ones. It could mean 250 miles to the gallon for hybrid cars and even better for solar panel ones.
We are already using lithium batteries in a number of electronic equipments such as BlackBerrys, iPods, computers and digital cameras.


Amazing what a desert can yield!

Please spare some lithium for Bipolar Disorder though.


Lithium for Manic-Depressive Disorder (Bipolar Disorder):

Sunday, February 22, 2015

Anorexia Nervosa: Eating Disorder Awareness Week



Anorexia Nervosa & Tango: Minuchin & Argentina

First published Sept. 1 2012:


Argentina is famous for its Tango:
 
© Am Ang Zhang 2010


What about Anorexia Nervosa?

Alert readers would have noted a number of Anorexia Nervosa cases on this blog and in my book, The Cockroach Catcher and that Minuchin’s name has indeed been mentioned.

Regardless of what present day psychiatrists (and that includes those dealing with Anorexia Nervosa, Minuchin have in one way or another inspired us in our dealings with Anorexia Nervosa and of course families in general.

He has inspired me the most in my work with families and with anorexia Nervosa in particular.

He was born in Argentina and soon served in the Israeli army before continuing his training including that of psychoanalysis in New York. It may be of interest to readers that the new generation of psychiatrists including those in the US were no longer brought up in psychoanalysis and with that they have little understanding of both the personal psyche and the family dynamics that we grew up in. Of course psychoanalysis has its many faults but to totally dismiss it is very sad for mankind.

Minuchin above all helped me in my understanding of family dynamics and in turn in my personal dealings with problem families and Anorexia Nervosa.

Minuchin has recognized a group of family system characteristics that reflect the family dynamics of patients with anorexia nervosa:

Enmeshment:
This is a transactional style where family members are highly involved with one another. There is excessive togetherness, intrusion on other's thoughts, feelings and actions, lack of privacy, and weak family boundaries. Members often speak for one another, and perception of the self and other family members is poorly differentiated. A child growing up in this type of family learns that family loyalty is of primary importance. This pattern of interaction hinders separation and individuation later in life.

Overprotectiveness:
This refers to the excessive nurturing and protective responses commonly observed. How can the psychiatrist begin to argue against such a good trait! Pacifying behaviors and somatization are prevalent.

Rigidity:
These families are heavily committed to maintaining the status quo. The need for change is denied, thereby preserving accustomed patterns of interaction and behavioral mechanisms. Rigidity is commonly observed in the family cycle during periods of natural change where accommodation is necessary for proper growth and development. You must have seen families where for every single day of the week they eat the same meal year in year out.

Avoidance of conflict/ conflict resolution:
Family members have a low tolerance for overt conflict, and discussions involving differences of opinion are avoided at all costs. Problems are often left unresolved and are prolonged by avoidance maneuvers. Everyone would come up with a highly believable excuse. After all everyone is very clever!


Apart from classical Autism, parents of many sufferers of Anorexia Nervosa are amongst the most successful in their own profession. Many are CEOs of major corporations including Hospital Trusts and PCTs. Minuchin’s powerful understanding of the family dynamics has allowed me to navigate the very difficult terrain. More so than trying to learn Tango!A Brief History of Time: Anorexia Nervosa

First published March 1, 2008

 

Il faut manger pour vivre et non pas vivre pour manger.
(One should eat to live and not live to eat.)
- 
Moliere (1622 – 1673): L'Avare (The Miser)

Some hae(have) meat and cannot eat,
Some cannot eat that want it:
But we hae meat and we can eat,
Sae let the Lord be thankit.
- 
Robert Burns (1759 – 1796): The Kirkcudbright Grace
This is not about Stephen Hawking’s famous book that sold over 9m copies world-wide, but a collection of material that relates to Anorexia Nervosa in a chronological order. You see, I believe in free sharing of knowledge.
First introduction of the term Anorexia
Sir William Withey Gull (1816 – 1890) first used the term:
“In… 1868, I referred to a peculiar form of disease occurring mostly in young women, and characterized by extreme emaciation…. At present our diagnosis of this affection is negative, so far as determining any positive cause from which it springs…. The subjects…are…chiefly between the ages of sixteen and twenty-three…. My experience supplies at least one instance of a fatal termination…. Death apparently followed from the starvation alone…. The want of appetite is, I believe, due to a morbid mental state…. We might call the state hysterical.”
Source: Anorexia Nervosa (apepsia hysterica, anorexia hysterica).
Transactions of the Clinical Society of London, 1874, 7: 22-28.
Classic description of Anorexia Nervosa.
Earliest published accounts
Richard Morton (1637-98), a London physician: The Treaty in his book Phthisiologia, or a Treatise of Consumptions, first published in Latin in 1694.
Ernest-Charles Lasègue (1816 - 1883), a professor of clinical medicine in Paris: “De l’Anorexie Hysterique” containing descriptions of eight patients.
More recent views
Girl in a Chemise circa 1905 Pablo Picasso (1881-1973)
Tate Collection

Anna Freud’s psychoanalytic view (1958):
  • Adolescent emotional upheavals are inevitable
  • Anorexia Nervosa is the outward manifestation of the battle between the ego and eating, with the former struggling for it’s very survival
Bruch (1966): relentless pursuit of thinness
Crisp (1967 - 1980):
  • Anorexia nervosa serves to protect the individual from adolescent turmoil.
  • Anorexia nervosa reflects a phobic avoidance of sexual maturation.
  • Unsettling effects of sexual maturation at puberty may drive the female adolescent to a pursuit of thinness leading to greater acceptance, self-control and self-esteem.
  • Anorexia nervosa tends to appear in families with buried, but unresolved, parental conflicts.
Palazzoli (1978) on women’s role (not just Anorexia Nervosa)
  • Women are expected to be beautiful, smart and well-groomed.
  • They are expected to have a career and yet be romantic, tender and sweet.
  • They are expected to devote a great deal of time to their personal appearance even while competing in business and professions.
  • In marriage, they are expected to play the part of the ideal wife cum mistress cum mother.
  • They are expected to put away her hard-earned diplomas to wash nappies and perform other menial chores.
  • The modern woman is therefore exposed to a terrible social ordeal, and the conflicting demands and dual image of the female body as sex symbol and as commodity.
  • An adolescent girl may develop feelings of insecurity and alienation toward her changing body.
Finally, it is appropriate to close with two quotes:
L'appetit vient en mangeant.
(The appetite grows by eating.)
- 
Rabelais (1494 - 1553): Gargantua

One hath no better thing under the sun than to eat, and to drink, and to be merry ...
- Ecclesiastes 8.15

Friday, February 20, 2015

Anorexia Nervosa: From Magritte to Amanda!

Rene Magritte exhibition


Could the Cockroach Catcher have missed this exhibition?


Art Institute of Chicago’s new special exhibition, “Magritte: The Mystery of the Ordinary, 1926-1938.”

 “Magritte was an amazing artist who has much to offer us today,” said Stephanie D’Alessandro, the Gary C. and Frances Comer Curator of Modern Art at the Art Institute, who was instrumental in assembling this exhibition of nearly 80 paintings, plus collages, objects, photographs, periodicals and examples of the artist’s work in advertising.
“I think that living in an age of mobile phones, in which we are so used to acquiring all sorts of information with great speed — and assuming it is ‘correct’ — has resulted in a loss of the ability to let a picture really take us into its own world, with all its unique habits and customs. So working with installation designer, Robert Carson, I’ve tried to create a series of small, initially quite dark spaces that should help make the experience of each art work more intense and intimate, and will let your imagination tell you where you want to go.”
The Magritte show, awash in images at once grotesque and erotic, mundane and mysterious, unspools in more or less chronological order. It begins with the crucial body of work, both paintings and paper collages, that he created in 1926 and exhibited the following year in his first one-man show at the elegant Galerie Le Centaure in Brussels — a show greeted by mostly negative reviews. It moves on to his subsequent time in Paris, where he lived for three years, becoming part of the Surrealist circle led by the French poet and theorist, Andre Breton, and such artists as Salvador Dali and Joan Miro.

 Magritte reminds me of Amanda.

Amanda
         My old secretary Karen went to work for a plastic surgeon in the local hospital specializing in burns. Out of the blue she gave me a call. 

         “It is about Amanda. You should see her. She has all these scars on her.”

         It had been over two years since I last saw Amanda. It was rather sad as she had a real talent in art and I managed to secure the last ever support from the Education Authorities for accommodation for her at the Art College. But she dropped out after a year.  Nevertheless she still managed to make appointments to see me a couple of times before disappearing.  

         “Why don’t you ask her to arrange to see me next time she has a follow up at the clinic.”

         “That should not be a problem.”
         “But only if she wants to.”
         “I think you may still be of some help.”

         Well, Karen actually drove Amanda to my clinic late that afternoon and I stayed on to see her. Luckily Karen was still in the room with me when Amanda simply decided to lift her T-shirt. She was not wearing anything else underneath and what she revealed was a body covered in a number of three to four inches long keloidal scars. Some were actually over her breasts.

         Karen stayed as chaperone and Amanda did not seem to mind. In our work there are certain risks when you see young people on their own and more so when you see someone like Amanda. I sometimes felt rather unsafe with some of the mothers too.

         Amanda was first presented to me as a severe anorectic who more or less required immediate hospital admission. I put her in the paediatric ward rather than referred her to the hospital as at that time we were having some trouble with the quality of care there.

         At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either.  It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.

         Her body weight gradually picked up and it was time for some trial home leave. She pleaded with me not to let her go home even for half a day.

         I did not want her to become dependent on us and there was every sign that she had now settled in on the ward.

         She came back from home leave and decided not to follow our agreed contract. It was popular in those days to have a weight gain contract and we had one too. Of course now I realise how rigidity with a contract can have drawbacks. In fact in child psychiatry too rigid an approach often causes problems one way or another and it is one of the few medical disciplines with which strict guidelines are not a good idea.

         At the time, another patient was on the ward after a serious suicide attempt. She had been abused by her step-father and step-brother over the years. She had had enough and decided to end it all.  I was trying to sort out where she could go as there were all the child protection issues.  She became very friendly with Amanda.

         One day when I arrived on the ward, the Sister-in-charge handed me an envelope and said that Amanda would like me to read it first.

         I have since used the same two pages she wrote as teaching material. Most female junior doctors could not go through with reading it aloud. It is nice to think that years of medical training do not really harden someone. Or was it something too horrible to be faced with?  It was particularly upsetting when the abuser was Amanda’s father.

         Amanda was by then fourteen but her father had been abusing her since she was about eleven. Her mother worked night shifts and father would come to her bed room to tuck her in. This had been going on for as long as she could remember. She started to have budding breasts and her father would at first accidentally brush them and Amanda would be quite annoyed with that. Then one night he started fondling with her breasts and also outside her pants. She was so scared she froze and did not say anything. He went further and further until he penetrated her. She was bleeding quite badly and told her mother, who told her that was what happened to girls when they grew up. She knew what menstrual period was but she said this was different; but mum did not want to know and gave her a box of sanitary pads. Then her period started and she started to worry about becoming pregnant. Her father said it was not a problem and asked her to suck him instead. She recorded that she was sick every time. Then one day her father decided to try her “back-side”. It caused so much bleeding it stained her school skirt and when she told her mother she was bleeding from her “back side” she just said, “Don’t be silly.  It is only a heavy period.”

         It is disturbing even for me to give you the details now. But this is what is happening to many children and is happening all around the world. If anything, I probably have toned down the content of that letter. What has gone wrong with mankind?  I cannot say I know any better since my early cockroach catching days. 

         Then on the day I “forced” her to go home he picked her up and made her go down on him in the car on the way home when he parked on a lay-by.

         In the end it was the other girl in the ward who encouraged her to write to me. She told her that she suffered the same for a long time and was stupid enough to try and hurt herself before she could tell anyone.

         There was no time to waste to report this to Social Services. However, Amanda’s father, who worked at the local mental hospital, had a “breakdown” and was admitted under the Mental Health Act the night before all of this came out. Amanda was not aware of this.  When I showed mother what Amanda wrote, she just said to me, “He is in a mental hospital,” and walked out.

         It has taken me years to grasp that maternal failure plays a major role in family sexual abuse. This mother’s action says it all. Can’t you see he is mad?

         It was a most peculiar case. His psychiatrist refused to even let me know of his problem, citing patient doctor confidentiality. He obviously had not worked with child abuse. Mother denied all knowledge of the bleeding incidents and claimed that it was all in Amanda’s imagination and it became very hard trying to place Amanda because her mother would not acknowledge that there was a problem. At this time West[2] was arrested and it helped me at least to understand the unfathomable.

Magritte:
         One of the nurses who got on well with Amanda told me that I should look at her examination portfolio for art. Every picture was morbid.  One struck me with the René Magritte[3] style of surrealism. A body of a girl with a penis floating over what looked like a classical stone grave. The head was covered in cloth and separated from the body. There were many daggers on the upper body of this half-man half-woman. There was a sort of school in the distance with small figures of school children. The sky was normal blue with white clouds which contrasted dramatically with the central theme. There was no question that the sky was a Magritte sky, and so was the cloth covered head. The rest was original Amanda.

         I knew then from what I remembered of Erickson that the picture was not just about the past with which one naturally associated but also about the future. Yet it took me a few years to realise that it was about the cutting.

         She said she was now working as a waitress. Her teacher at college did not want her to do all the morbid paintings, so she quit. She had been sleeping with virtually any man she came across and every time she would cut herself afterwards. She wanted to feel something, she told me. What was worst was that whenever she was with a man she saw her father.

         What an outcome. I had spent so much time with this girl and this was in the end what happened. She said one day she would be in a mental hospital like her father, but she hoped to kill herself before then.

         I no longer remember Amanda as a severe anorectic but rather a very talented artist who suffered serious abuse. Yet in a society which prides itself in social care, she did not become a famous artist with a high income, telling all about her history of abuse in front of a famous chat show host. Nor did she become a movie star telling all after drug and alcohol rehab.

         Instead she was on benefits and I am struggling hard to find something uplifting to end this story.

It has taught me one thing: Anorexia Nervosa may be just a manifestation.

The Cockroach Catcher Chapter 33  The Peril of Diagnosis 


Wednesday, February 18, 2015

Anorexia Nervosa: The NHS & Safety Net.

In The Cockroach Catcher, in the opening chapter I recalled an Anorexia Nervosa patient that has been “dumped” by her Private Health Insurer.

Girl in a Chemise circa 1905 Pablo Picasso (1881-1973)
Tate Collection

This patient’s father works for a medical supplies company that continued to insure the family. Even then the Health Insurer chose to limit her treatment to 18 months.

Why? Because there is a safety net: The NHS.

Health Insurers write their own rules.

Why? Because there is a safety net: The NHS

“….Ethics in medicine has of course changed because money is now involved and big money too. What was in dispute in this case was that the private health insurance that sustained Candy through the last eighteen months had dried out. The private hospital then tried to get the NHS to continue to pay for the service on the ground that Candy’s life would otherwise be in danger. The cost was around seven hundred pounds a night….’

Let us not forget that many private hospitals can make more money from the NHS because the NHS does not exclude. The NHS pay for everything including those Private Health Insurers chose to exclude.

“……A quick calculation gave me a figure of over a quarter of a million pounds per year at the private hospital.  No wonder they were not happy to have her transferred out.  Before my taking up the post, there were at one time seven patients placed by the Health Authorities at the same private hospital. Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private hospitals springing up for the sole purpose of admitting anorectic patients and nobody else. It is a multi-million pound business. Some of these clinics even managed to get into broadsheet Sunday supplements.  I think Anorexia Nervosa Hospitals are fast acquiring the status of private Rehab Centres. Until the government legislates to prevent health insurers from not funding long term psychiatric cases, Health Authorities all over the country will continue to pick up the tabs for such costly treatments……”

I did not agree to that patient staying on at the private hospital paid for by the NHS. That hospital did not like me!!!

The Obama Health reform is dealing a big blow to Health Insurers as by 2014 they will have to take all comers and cannot exclude pre-existing conditions not to say dumping someone like my Anorexia Nervosa patient. Until then, the State or the Federal Government steps in.

Gov. Arnold Schwarzenegger of California, a Republican gave a rousing endorsement of President Obama’s health plan.  New York Times reported today.

The new government in a week’s time should take the first step in legislating against Health Insurers “dumping” patients because of psychiatric diagnosis or so called chronic conditions. That way, private hospitals and insurers can fight it out amongst themselves. At least  the small pot of NHS cash would be safe. That would be a first step.

I doubt if any government would follow Obama’s extremely courageous move of legislating against excluding pre-existing conditions but we could watch what happens in a few year’s time. If we can at least secure the position of those already insured we could save the NHS a great deal of money.

Unlike the US we have a safety net: the NHS.

Let us protect it. 

How? 

Saving NHS: Control Health Insurers!


Summary of a popular post:


  • Ends discrimination against people with pre-existing conditions.
  • Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.
  • Limits premium discrimination based on gender and age.
  • Prevents insurance companies from dropping coverage when people are sick and need it most.
  • Caps out-of-pocket expenses so people don’t go broke when they get sick.
  • Eliminates extra charges for preventive care.
  • Contribute to an ABTA style cover.


                     
We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “individual personalised budget” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way their will be real choice and insurers will be competing with each other to provide the worst deal.

Why?

What Health Insurer will want the business? 


Perhaps they will go back to the US and we will have our own NHS back.

The Times:  The internal market has been a costly disaster