Monday, September 25, 2017

Sadness & Mahler :My first adolescent patient!





Yosemite ©2007 Am Ang Zhang

I am lost to the world
with which I used to waste so much time,
It has heard nothing from me for so long
that it may very well believe that I am dead!
 
It is of no consequence to me
Whether it thinks me dead;
I cannot deny it,
for I really am dead to the world.
 
I am dead to the world's tumult,
And I rest in a quiet realm!
I live alone in my heaven,
In my love and in my song.


I do not know Mahler. No, not when I started at the Tavistcock in 1972.

One day at our referral meeting, a very interesting referral turned up from none other than the much revered paediatrician at the Royal Free up the road from us. In the early 70s referrals are specific to the individual teams and I have a suspicion that she likes to refer to my consultant as much of her cases landed into our team. I suspect that Dr Collingwood’s solid paediatric base having worked with Winnicott may have something to do with it. She is a very flamboyant character as I have met her at a couple of child protectopm conferences where she is much revered or indeed feared. I must admit I prefer her kind of consultant that knows her specialty and show great respect for similarly capable colleagues. Her flamboyance command much respect.

Dr Collingwood does not routinely put patients on psychotherapy as very often the management is through good practical advice. This is more so with this paediatrician and so when we got this referral where she specifically asked if the 14 year old could have psychotherapy and preferably with someone that knows a bit about music, we all gasped but nobody said much. 

Looking back now, it is amazing that I joined Tavistock not knowing what to expect and after nearly three years of training there, it has never occurred to me that one should use any medication on children. I have never once written a prescription. I know of a friend in California where the son was diagnosed with ADHD and was on Ritalin until well into late teens. Her youngest sister was diagnose Schizophrenic because she had such a vivid imaginary friend and was put on one of the newer antipsychotics. Yes, you guess right she is now a balloon. Not to be outdone, the middle sister who is quite a charmer was diagnosed, you guess right, bipolar but was not put on Lithium but the other mood stabiliser and a novel antipsychotic.

My prime years of child psychiatric training in a drug free environment was fantastic in ways that I only realised years later.

Miss Frys spoke up for me, “Dr Zhang is very fond of music and he is forever carrying boxes of discs from the Swiss Cottage library!”

Well, that settles it then. But this will be my first adolescent. The small kids I can cope by playing with them. This is real talking therapy now. I put on a brave face as they are all looking at me now at the meeting.

So I told them that from an early age, I sat in on my cousin’s piano lessons, then I was introduced to classical music at primary school by my village friend. My first record he lent me was Beethoven’s 5th Symphony. I have built my own sound system at high school as it was the cheapest way to get good sound and I even ran the school music club playing classical music at lunch times. Moving to England meant that my music playing equipments were left behind but I did purchase a reasonable disc playing set up and on Miss Frys’ tip, use our Swiss Cottage library extensively.

“Your favourite composer?”

“I now pick up some unusual works. At Swiss Cottage Library, I tend to go for new records and often box sets so that they are often complete segments of works. Older records are rather scatchy so I tend to look out for brand new arrivals and sometimes they can be some rarer music.”

“Like Mazart’s Quintets!”

So one does not escape the eyes of Miss Frys who is also a keen music lover and often goes to the Royal Festival Hall as she lives virtually next door to it.

“And Peter Grimes, which of course is Dr Collingwood’s territory!”

I love the way the referral meeting turned into a cultural one. Looking back now, it has as much significance to the likes of Nobel Laureate Kandel as it did in my humble early child psychotherapy training.

Dr Collingwood has a nice bungalow in Aldeburgh which is of course the home of Benjamin Britten and Peter Pears. The opera, I have never heard of until one day the librarian was placing new discs onto the shelves and hinted to me that it was a great one to listen to. Dr Collingwood is one of the volunteer ushers at The Maltings and some years later when our family spent a week at Aldeburgh and we pay pilgrimage to The Maltings for a Peter Pears recital. We met Imogen Holst, daughter of the composer at the sea front.

It took over 30 years for us to see a performance of Peter Grimes at the Royal Opera House[1].

I have by now seen quite a few children in therapy and I have on the whole been quite relaxed about using the toys and drawings throwing in Winnicott’s squiggle game[2] now and again for the children who are a bit too old for the set toys we have. It is interesting that most other junior doctors are more at ease with the older adolescents where they often come round to our case presentations to hear about the younger kids. It was only when I became a consultant that I realise it was unusual to have a preference for the very young children whereas many of my colleagues somehow avoided them.

Jonas

Now what do I do with this adolescent that our paediatrician thought needs some fairly deep therapy as he seem to be struggling with everything and most serious of all with his mother.

Unlike working as a consultant, I did not get to see the parents at all. Most of the time it would have been Miss Frys or her Social Worker trainee. The Psychologist only access a child if referred by the Consultant.
Some other time, Dr Collingwood would see the parents.

As it turn out, Jonas’ father is a Surgeon at the Hospital where the paediatrician works and his mother teaches piano at his school, one of the best known state school in the area. It is so good that many of the professional class living in Hampstead send their children there. Do we still wonder why good areas have good schools! Of course it is only natural that good areas with intelligent pupils attract good teachers. It goes on.

I have at least learned from Winnicott’s squiggle game the importance of the therapist’s quick response and spontaneity and why should talking to the older child be any different.

Traditional psychotherapist will probably throw up in horroe but at least those I am learning from do not have or suffer from that kind of rigidity.
Much later as a consultant I have adapted this approach well as it helps to establish rapport very quickly especially with parents.

But my supervisor wants to throw me into the deep end and I have no idea what to do.

Jonas first noticed the Mondrian on the wall.

“Did some kid do that? Very neat!”

Perhaps he is right. Picasso wanted to draw like a kid too.

Then he noticed the records I was about to return to the library: Mozart Quintets.

“Mozart’s best as he wrote for himself!”

That was how we started. Some might think I plotted it by putting the records on my desk. I wish I could have claimed to have planned it. I think sometimes spontaneity may be best.

But this boy knows his music and yet I am not quite prepared for what he gave me as the sessions progress.

Many thought the therapist is suppose to be a mirror and be there to let the patient see more clearly about their own psyche. Others are more assertive and felt compelled to make interpretations not realising that often one is limited by ones own psyche or understanding of it. Hence the need for some personal analysis to deal with that aspect.

There is of course a world of difference between reflection and interpretation. My personal feeling is that there needs to be a balance between the two.

Psychotherapy is thus quite far removed from medical history taking. In a severe medical episode, there is a need to get a clear view of the events leading to the episode in order that appropriate investigation is carried out to be followed by the right course of treatment.

Psychotherapy afforded us with the luxury of a deeper understanding of the patient without having to ask probing questions. It goes without saying that with the more frequent sessions of therapy the therapist gains a very deep understanding of the patient without the need to go through an intensive and compact history taking. We also tend to remember these patients literally for ever.

Jonas hardly sees his father as he is busy his patients. His mother would have been a concert pianist but she had to make a choice between bringing up Jonas and looking after a rather nice house on the Heath. But she has high hopes for Jonas, her only child.

Yes, to be something she could only dream of, a concert pianist. Jonas has been a good piano player but once he turned nine told mother he would like to learn the violin.

He picked that up in no time and is now on to Grade 8 exam for violin. He left his Piano at Grade 5.

As I progressed with Jonas, it became clear the very strange role I am playing. I am his mother that he can talk to and argue with. And perhaps practice with. In truth it was easier as I am not his mother and on the other hand I am. But I am the one who could provide some answer his mother would not give him.

One day I have a complete set of Brahms Symphonies on my desk, from the library of course, and he casually asked if Brahms was my favourite composer or not.

Brahms 1st Symphony was a present given to me by one of my uncles when I made my amplifier. He worked for Abbotts in Hong Kong and when I got to medical school, he gave me my Littmann Stethoscope.

“I love the 1st especially the solo violin part in the last movement.”

“Well, you should listen to Mahler as he used various bits of singing unlike Beethoven’s Choral Symphony. And my best Mahler is his Third Symphony, though everybody else I know prefer the 2nd.”

The truth is I have two commuting friends that are fond of music and Mahler has not been one they talk about.
Yosemite ©2007 Am Ang Zhang
I tried that day to secure any Mahler and could only find one: Das Lied von der Erde.

It was a shock to my commuting friends especially when they read the details: Chinese poems translated by a German?

During the next session, I have not seen Jonas more enthused and energetic. He could not wait to tell me more about Mahler[3]. The 3rd Symphony[4]s all about nature and is so positive and energising.
I have to say now that I have probable gained more from this one patient than I have from any other. To be introduced to Mahler at the time when London was just waking up to it and wake up it did.

We were able to talk about the struggle of Mahler and of the sadness of the death of his daughter and eventually him dying of Rheumatic Heart Disease[5].

One day he was able to declare that his struggles were nothing compare to Mahler’s.

It is interesting that he never really talked about his own sadness as Mahler’s overshadow his and yet in true traditional psychotherapy style he has gain his own insight.

His time with me, or was it my time with him was coming to an end. Dr Collingwood is highly intuitive and on the recommendation of my psychotherapy supervisor helped me to terminate the therapy. It was perhaps a credit for a state funded system like the NHS that one does not need to hang on to therapy for ensuring adequate income. The main danger for privately funded psychotherapy is the unnecessarily prolonged therapy periods with the result that the patient is addicted to the therapist or the other way round.

On his last session, he told me he has got his distinction in Grade 8 Violin but he did not want to be a violinist.

He wants to be a conductor.

As I wrote this, I Googled and found that he is now a conductor for a German Opera Company.

No, Jonas is not his real name.

In 2009, Das Lied von der Erde was performed in Hong Kong and The Mahler 3rd in December of 2016[6], a sort of home coming. Thank you Jonas for introducing me to Mahler.




Nature & Mahler: Royal Festival Hall!


Related:








[1] http://cockroachcatcher.blogspot.com/2011/06/peter-grimes-individual-against-mass.html
[3] http://cockroachcatcher.blogspot.com/2010/08/proms-mahler-nature.html
[4] https://www.youtube.com/watch?v=9Yr720ftjaA
[5] http://cockroachcatcher.blogspot.com/2009/11/sadness-songs-superstition-mahler_29.html
[6] http://www.hkphil.org/eng/concerts_and_ticket/concerts/concertdetail.jsp?id=554

Thursday, September 14, 2017

Eric Kandel: From Memory to Memory!

Eric Kandel, M.D., who was awarded the Nobel Prize in 2000 for discovering molecular mechanisms of memory storage, told the crowd at last week’s Flexner Discovery Lecture that he has recently become interested in memory in the aging brain. “We’ve been studying age-related memory loss, and not a moment too soon,” quipped the 87-year-old Kandel, University Professor and Fred Kavli Professor in the Department of Neuroscience at Columbia University.
“There are many people in the field…who think that the Aplysia rather than the investigator should have won the Nobel Prize,” Kandel said.
In more recent work, Kandel and his colleagues have turned their attention to age-related memory loss. The researchers wondered, Kandel said, if memory loss during normal aging is a distinct process or an early phase of Alzheimer’s disease.
They determined that mice, which do not experience spontaneous Alzheimer’s disease, also experience age-related memory loss, suggesting that the two processes are distinct, he said. Other studies showed that brain regions involved in age-related memory loss and Alzheimer’s disease are different.


©2015 Am Ang Zhang

No I did not do any diving in Patagonia!


We were having dinner at our Ecocamp in Patagonia with a very interesting couple.
The husband is aiming to climb the Matterhorn and somehow in the conversation we talked about their other adventures that included Diving. I show them some of my underwater pictures. Somehow Nudibranch was mentioned and as it turned out we exchange email addresses and became good friends.

Nudibranch reminded me of Aplysia and Kandel:






Nudibranch © 2009 Irene Man


Nudibranch is so named because of its naked gills.
Here is a description in The National Geographic:

Nudibranchs crawl through life as slick and naked as a newborn. Snail kin whose ancestors shrugged off the shell millions of years ago, they are just skin, muscle, and organs sliding on trails of slime across ocean floors and coral heads the world over.

Found from sandy shallows and reefs to the murky seabed nearly a mile down, nudibranchs thrive in waters both warm and cold and even around billowing deep-sea vents. 


So why, in habitats swirling with voracious eaters, aren't nudibranchs picked off like shrimp at a barbecue? The 3,000-plus known nudibranch species, it turns out, are well equipped to defend themselves. Not only can they be tough-skinned, bumpy, and abrasive, but they've also traded the family shell for less burdensome weaponry: toxic secretions and stinging cells. A few make their own poisons, but most pilfer from the foods they eat. Species that dine on toxic sponges, for example, alter and store the irritating compounds in their bodies and secrete them from skin cells or glands when disturbed. Other nudibranchs hoard capsules of tightly coiled stingers, called nematocysts, ingested from fire corals, anemones, and hydroids. Immune to the sting, the slugs deploy the stolen artillery along their own extremities.


Memory & Knowledge: Talmud & Taxi

In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel was giving his lecture. I was fortunate enough to be able to secure a seat.

"Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes." Eric Kandel.

In his book In Search Of Memory, he remembered his arrival in New York in 1939 after a year under the Nazi in Vienna:

“My grandfather and I liked each other a great deal, and he readily convinced me that he should tutor me in Hebrew during the summer of 1939 so that I might be eligible for a scholarship at the Yeshiva of Flatbush, an excellent Hebrew parochial school that offered both secular and religious studies at a very high level. With his tutelage I entered the Yeshiva in the fall of 1939. By the time I graduated in 1944 I spoke Hebrew almost as well as English, had read through the five books of Moses, the books of Kings, the Prophets and the Judges in Hebrew, and also learned a smattering of the Talmud.”

Eric Kandel/Amazon


“It gave me both pleasure and pride to learn later that Baruch S. Blumberg, who won the Nobel Prize in Physiology or Medicine in 1976, had also benefited from the extraordinary educational experience provided by the Yeshivah of Flatbush.”

In Hebrew and English!!! That did not seem to have done him and Blumberg much harm. Right now some governments seem hell bent in doing away with rote learning and that includes some medical schools.

Lord Brain:
When I was training in London in the 70s, I spent some time at Queen Square. Those in the know will recognize it as the place for neurology this side of the Atlantic. It was drilled into us then that sadly we were given a number of brain cells when we were born and it was all downhill from then on or something to that effect. It was well known that neurologists were great diagnosticians but for most neurological conditions, not much could be done. How depressing indeed. Even as recently as four weeks ago, I heard a young doctor told his father that there was nothing he could do with his brain cells. One is given so many at birth and no more can be expected. Lord Brain (1895-1966) would have been so proud.


Knowledge:

Yet it was also London that shook the world with new discoveries about the brain, and the study was on the most unlikely group of people: Taxi drivers. Their “KNOWLEDGE” was the basis of our knowledge on brain plasticity today. The “KNOWLEDGE” is a term officially used to describe the test the Taxi Drivers had to take to get the license to drive Taxis in London. Streets in London have evolved over time and are not on any grid system at all. Early postmortem examinations led some pathologists to note the small size of the Taxi drivers’ frontal lobes. Yet actual weight measurement showed that size was all relative. It was the enlarged hippocampal region that created that impression. Later work using modern scanning techniques confirmed the early impressions.


Kandel & Doidge: Neuroplasticity & Memory.

Monday, September 11, 2017

Trauma and Human Resilience: II



©2013  Am Ang Zhang  

It seems to be against common sense to suggest that talking may not be good for severe traumatic experiences. This is more so for someone brought up on psychoanalysis; yet, the evidence is clearly against talking especially in severe trauma.
In 
The Cockroach Catcher:
The speaker was a Senior Registrar from the Maudsley.

"......He was a Registrar at the time of the King’s Cross fire. He was just coming out of the station when the accident happened, and so was at the front line so to speak not just as a pedestrian but also as a psychiatrist. He became interested in PTSD (Post Traumatic Stress Disorder) and did a fair bit of research on King’s Cross and other disasters.

He quoted a number of cases, including the Herald of Free Enterprise disaster. There were those who despite help of all kinds would commit suicide. Many were heroes in that they saved many lives. Yet the feeling that they did not deserve to live eventually overtook them and they committed suicide.

What was most surprising was how the group that had counselling generally faired worse, much worse than those without any counselling. The group that did best were the ones that drank, and drank a fair amount.

It was not his intention to promote vodka but he thought we could not be kept from the truth……

His research showed that talking about the incident seemed to make things worse, much worse than anyone ever imagined……”

From To talk or not to talk: Trauma & Human Resilience Part I.


         Then came September 11. I remembered I was on holiday in Spain when it happened. I had just finished golf. I put my clubs away and went to the club house for a drink with my playing partners. As I approached their table, I sensed that something was wrong. There were no drinks.
         Then one of them said, “One of the World Trade Centre Towers is down!”
         I was trying to see if I heard right.
         “In New York?”
         “New York.”
         Then moments later, the Spanish waitress came out and said to us, the second tower was down too.
         I rushed back to our villa and shouted to my wife to turn on CNN and tried to contact our children, one of whom worked in Manhattan.
         Lines were dead.
         Luckily, an Email came through our other daughter who was in England: Sis OK, at a meeting on 55th Street. Now trying to walk home to Brooklyn.
         What a shock.  Unlike my parents’ generation we have had a long period of peace and prosperity but now everything was shattered.
         The following day my office put a call through and I talked to my Associate Specialist.
         The clinic just had an urgent referral. A local girl was referred. Very disturbed by what happened as one of her father’s good friends was one of the pilots whose plane went down. The family spent many holidays with them in their Florida home and she was now most upset.
         “Whatever you do, by all means talk to the parents but not to the girl. No one should see her. They should not turn on the TV and avoid any reminder of what happened.”
         I then nearly said, “Give her Vodka, Gin or similar,” but I did not.
         I gave the next best thing.
         “Put her on a short course of Benzodiazepine to let her sleep for a few days.”
         It shocked my Associate Specialist. It was not a drug I normally used, if at all, and why now?
         Well, whatever happened, all I could say was that the family was in total agreement and months later my Associate Specialist told me that it was brave of me but it seemed to have worked for this girl.
        
        
         In July last year I met a young couple at the swimming pool of our holiday condo. I thought they were Chinese but it turned out they were Vietnamese Chinese.
         We started chatting. He said he left Nam (Vietnam) on the last day.
         Jokingly, I said, you mean you were on the Helicopter?
         “Yeah, how did you know?”
         “You looked too young to be working for the Embassy.”
         “My mum worked there. But my story was nothing, you should hear hers.”
         His wife, an elegant looking petite Chinese swam closer.
         “So, tell me.”
         Well, she came out later. Her mother put her and four sisters on a junk (a Chinese fishing boat), one of those that took refugees out of Nam for an exorbitant fee and generally it had to be gold. Their boat sank outside Hong Kong but they swam ashore. She spent the next three years in one of the Hong Kong camps.
         “Yes, I remember those.”
         “I know - the stench. We got used to it.”
         Those camps were run under the auspices of the United Nations but the UN never really paid Hong Kong a single dollar. However that is beside the point. Conditions were very poor and one could hardly decide if it was Hong Kong’s or UN’s fault. Every time we drove past it was like passing a local authority rubbish tip. We had to wind up the windows. Yet there were politicians who felt they needed to keep it bad to deter people. They continued to flow in right up to the handover. As it was still under British rule, Britain tried its best to keep people from going to Britain. They needed not have worried. Most wanted to go to U.S. An irony really.
         I said something that sounded like an apology, an apology for Hong Kong, and for mankind.
         “No. It’s fine. I am not bitter. We waited and we got to the U.S. There was nothing you could have done anyway.”
         She told me someone suggested that she should have some therapy. She never did.
         “Some things you can never change. If it happened it happened.”
         But she managed to get most of her family out of camps and settled in the US. She was very successful in her business and her only regret was that her parents never made it.
        
         What a story of human resilience and triumph over adversities.
         And I can still remember that lunch time meeting and the learning from King’s Cross.



Now mountains are once again mountains,
and waters once again waters.




The Cockroach Catcher















Latest Views on the book:


5.0 out of 5 stars A Must-read for Students of Psychiatry August 10, 2014
Format:Paperback
We all have stories to tell with regard to our experiences as physicians. Zhang is one of our medical school classmates who took it to a different level by writing and publishing a book. The book details how it all started, from the time his family moved to Hong Kong from China, to his years in medical school, to his experience as a child psychiatrist in the UK. The book is full of interesting case studies of actual patients he saw and the challenges he faced dealing with them.
I was captivated by many of the interesting stories in the book. It’s a must-read for all students of psychiatry. It also makes for good reading material for anyone during their leisure moments.

From another doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

My 80 year old Mum has a long-standing habit of collecting old newspaper and gossip magazines. Stacks of paper garbage filled every room of her apartment, which became a fire hazard. My siblings tricked her into a prolonged holiday, emptied the flat and refurbished the whole place ten years ago. ……My eldest son was very pretty as a child and experienced severe OCD symptoms, necessitating consultations with a psychiatrist at an age of 7 years. The doctor shocked us by advising an abrupt change of school or we would "lose" him, so he opined. He was described as being aloft and detached as a child. He seldom smiled after arrival of a younger brother. He was good at numbers and got a First in Maths from a top college later on. My wife and I always have the diagnosis of autism in the back of our mind. Fortunately, he developed good social skills and did well at his college. He is a good leader and co-ordinator at the workplace. We feel relieved now and the years of sacrifice (including me giving up private practice and my wife giving up a promising administrative career ) paid off.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.

From Australia:

I have finished reading The Cockroach Catcher and thoroughly enjoyed it.

Zhang, I particularly liked the juxtaposition and paralleling of your travel stories and observations with your case studies, Of course, I could appreciate it even more, knowing the author and hearing your voice in the text. Because I’m dealing with anorexia, ADD and ADHD students I was very interested in your experiences with patients and parents and your treatment. Amazing how many parents are the underlying causes of their offspring’s angst. It was an eminently readable text for the medically uninitiated like me. Keep writing, Zhang

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