Saturday, August 31, 2019

Nazca Booby and Siblicide: Jenner and Cuckoo.

We were fortunate enough to be in Galapagos and to be precise on Genovesa Island where two of the three main Boobies are abundant.










What I did not realise was that this Nazca Booby practices Siblicide: 
 

The Nazca booby, like its relatives, practices siblicide; however, it takes siblicide to a whole different level. While the female typically lays two eggs, the parents never raise two young. The first egg is normally laid four to nine days before the other. This asynchrony is directly proportional to the hatching asynchrony, which is among the longest of all birds. This delay is a death sentence for the second chick that hatches, as the first can easily push it out of the nest, and it does so in every case, without fail. Once outside of the nest, the parents do not acknowledge the unwanted chick and it quickly dies from either starvation, temperature change or predation.

Siblicide is not uncommon among boobies. However, blue-footed booby chicks practice what is known as facultative siblicide, in which they kill the weaker chick only if there is not enough food. On the contrary, Nazca booby siblicide is obligate and unconditional. Experts are still not certain as to the cause for this unreserved murder between siblings. It is possible that the fierce trait developed as a result of recurrent food scarcity, as by killing its weaker sibling the older chick would be entitled to all of the resources that the parents bring. On the other hand, it is possible that the siblicidal allele was developed due to some past selection pressure, such as food scarcity, and was never lost.





All Photos ©2019 Am Ang Zhang

It reminded me of Jenner and his observation of Homicide in Cuckoos:

When I visited his home in Glouscestershire, the curator of the small museum, who was extremely knowledgeable, took pride in telling us how Jenner’s great work on Cowpox vaccination upset the medical establishment on the one hand, and how his observation on the murderous ways of the Cuckoo newborns upset the gentlemanly world of the Ornithologists on the other. It was the Royal Society that awarded him a Fellowship for his keen observation.

His work on Cowpox vaccination in the prevention of Smallpox was met with hostile responses. The medical world that was dominated by London at the time could not accept that a country doctor had made such an important discovery. Jenner was publicly humiliated when he brought his findings to London. However, what he discovered could not be denied and eventually his discovery was accepted – a discovery that was to change the world.


Thursday, August 29, 2019

Underclass: The Old Beggar



Hasselblad/150mm lens.

Available light


Film: Kodax TMax 100

Printed on Record Rapid paper/ Selenium Toned

Selenium Toning is for archiving prints and imparts a lovely tone depending on concentration.


6 comments:

HyperCRYPTICal said...
Excellent portrait - you can almost hear him thinking.

Anna :o]
Cockroach Catcher said...
Thanks.
Sam said...
It's the light that does it Anna, but the man is actually 'blank', staring without thought ... and that's the brilliance of the photography here; capturing the 'nothingness' that comes with dispair ... and poverty

... but I never liked the word 'underclass' ... or 'subhuman', two of the same vocabulary, because of the degradation to humanity that is associated with such expressions. Surely, humanity with all it's ills, is still less vicious than that, or am I underestimating our 'exclusive' arrogance?

Well done, as usual, CC, you've made me think, and stirred some emotions :-)
Cockroach Catcher said...
With the recent debate on the UNDERCLASS I thought I would do a send up without words.

I am glad you liked the portrait. Photography portraiture is difficult as it was only a split second thing unlike painting which often takes many sittings (painting from photo is the modern way and that is why much of the BP stuff is not good in my humble opinion.

Saw One Man, Two Guvnors at the National: all the classes were bad----Public School class, butler class, mafia class, lawyer class, waiters class.
Sam said...
Sarcastic play, funny too, in parts.

... one of the most amazing, and very disturbed, paintings done from a photo, is [Gorky's mother and child]. He was influenced by Cezanne and Picasso, but that painting has something, a life of it's own, despite it's artist death long ago ... I find it scary and very disturbing ... Gorky needed you CC, check him out :-)
Cockroach Catcher said...
In Thailand and other Buddhist countries, the monks are doing a good turn to us ordinary people by begging so that we can buy our way out of hell.

It is the same with many Catholic countries and Portugal is one of them.

He was given some bread so from under his seat he pulled out some raw garlic cloves and ate the bread with it. He is going to live a long life.

My old man was doing good, much good.

COI: I did give him some money, after the photo of course.

Monday, August 19, 2019

Anorexia Nervosa & Mountains: Misguided Belief in Psychiatric Diagnosis!






 ©2016 Am Ang Zhang 

Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains,
and waters are not waters.
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.


                                                                                                   Adapted from Ching-yuan (1067-1120)

There is a misguided belief that Psychiatry is like other branches of medicine, that we make diagnosis as if we know the definitive cause, course of treatment and prognosis.


I accept that even in other branches of medicine, what we used to know sometimes can be turned upside down overnight. We only need to look at the evolution of the understanding and treatment of Leprosy and Tuberculosis over time, and in the modern era, that of HIV/AIDS.

I was brought up to understand that “scientific truth is nothing more than what the top scientists believe in at the time.” In this modern era of “biotech” approach to medicine, new understanding is yet to be found for many conditions. In these cases, are we content to continue with empirical and symptomatic approaches?


Anorexia Nervosa comes to mind and this is one of the conditions that have for want of a better word captured the imagination of sufferers and public alike. I have already posted an earlier blog on its brief history.


Sometimes a diagnosis as powerful as Anorexia Nervosa can be a hindrance to the improvement of “sufferers”. Over my years of practice, I found that those who did well were cases where we indeed moved away from the medical/conventional psychiatric model to a somewhat paradoxical approach.

When I took over the adolescent unit as its consultant in charge there were six Anorexia Nervosa patients in varying stages of emaciation or weight gain depending on from which side you want to look at it.  It is not always wise to have so many anorectic patients together as they do share tricks with each other and it is often more difficult to customise treatment.




         What needed my urgent attention was of course Sammy. Sammy had a very feminine name but preferred the nickname Sammy. Sammy’s Section was due to expire in less than 14 days and I had to compile a report for the Tribunal which would be sitting to decide on her fate.

         It was perhaps a sign of our failure as psychiatrists to effectively treat Anorexia Nervosa that eventually case law was established to regard food in Anorexia Nervosa as medicine. Therefore food may be used forcibly to treat Anorexia Nervosa when the condition becomes life threatening. 

         The usual test of mental capacity no longer applies. Instead the law is used forcibly to feed a generally bright and intelligent person “over-doing” what most consider to be “good”.  They try to eat less and eat healthily by avoiding fat and the like and wham we have the law on them.

         I have to admit that I have not liked this aspect of Sectioning. Unfortunately it is used often, judging by the high numbers of tube fed patients.

         On the other hand not everybody is able to treat Anorexia Nervosa patients or, in reality, do battle with them. It requires experience, energy, time, wit, charisma and often impeccable timing. However, sometimes I do wonder if we are indeed doing a disservice when we take things out of parents’ hands by agreeing to take over.

 ©2016 Am Ang Zhang 
         With hindsight and upon reflecting on a number of cases I have dealt with, I often wonder: if hospitalisation had not been an option at all, would improvement rate and, more importantly, mortality rate have been any different.

         We do not section people for smoking, drinking, or doing drugs, which all endanger life. Nor do we stop people running the Marathon or eating raw oysters when these activities regularly lead to mortalities.

         Society is coming round to do something about over-eating in children but it will take some time before they apply the Mental Health Acts. 

         To me, the moment a psychiatrist turns to the law he is admitting that he has failed. 

         At least that is my view and if I perpetuated the Compulsory Order with Sammy, I too would be part of that failure.

         There had been no weight gain in Sammy despite the tube feeding and the debate was: shall we increase the feed or shall we wait? Everybody just assumed that she would stay on as a compulsory patient.


         Despite bed rests and even more embarrassingly the use of bedpans, many Anorexia Nervosa patients managed not to gain weight whatever we pumped into them. The balanced feeds were in fact quite expensive. There was no secret that they were aware of the exercises they could perform even on bed rest and the determination not to put on weight had to be seen to be believed. If such determination was applied elsewhere I was sure these young girls could be very successful.

         I had to find an answer, an answer for Sammy and an answer for myself.

         Being forced to eat by the State remained the treatment of choice for everybody except for one stubborn consultant.

         “At least we did all we could,” my staff constantly reminded me.
         “And she is the most determined of all the Anorectics we have right now.”
         More reason to show the others that this new psychiatrist had some other means than brute force, I thought to myself. 

         Yes, I could be as determined as they were.

         The hours of family therapy only brought about accusations and counter accusations with hardly any resolution. Middle class families have certain ways of dealing with things where some branches of family therapy are not particularly good at all.

         The modern trend is certainly moving away from blaming families.  Or that is the rhetoric of most who write publicly about it.

         Whatever the official line, families cannot help feeling blamed.

         “If we are not to blame, why do we need family therapy?”

         “There are so many other families like ours.  Why do they not have the same problem?”

         We may reassure them that there are and that is the truth, but the truth is that there are also Anorexia-free families.

         Yes, it might help if they do find a gene like they did with obesity.  Yet that cannot explain why there are more extremely obese people in say the U.S. which collects gene pools from across the globe.

         So Sammy’s family had the full benefit of eight sessions of family therapy by two very experienced therapists. In the end, there was just a lot of recrimination between all parties including the therapists and all agreed it would not be the way forward. That was when tube-feeding started.

         Minuchin[3] dealt with over-involvement, over-protectiveness and conflict avoidance in these families with no special apology on whether he blamed the family or not. He used to start with a meal session with the family. His success, like many such methods, probably had more to do with his charisma than his method and is thus difficult to replicate.

         For Sammy and her family the message was simple and clear enough, no matter how hard we lied.

         The family had failed and the hospital had to take over.

         That was the blunt truth. 

         But the hospital had failed too and we had to resort to the Mental Health Act on one of society’s most sensible and decent and safest citizens. 

         I decided enough was enough. I could no longer perpetuate the no-blame approach. I could no longer continue to hide behind the power conferred onto me by the law. 

         In short, I had to reverse just about everything that had gone on before, and more.

         Just two weeks before the tribunal sat we had the big review meeting. To most at the unit, the review was fairly routine as there was hardly any choice – a full Section for Hospital Treatment primarily intended for difficult to treat Schizophrenics and difficult to control Bipolars in the acute manic phase. Sammy would be “detained at Her Majesty’s pleasure”, and classed with the likes of the few psychotics who had committed the most heinous murders. To save Sammy’s life, it would be natural to continue with the Mental Health Act.

         Yes there would be weeks of tube feeding and bed rest, but the State had to take over the complete care of this bright young thing for her own sake.

         I could not see any other way either.

         Unless …….I could reverse everything that had gone on before.  

         If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative.  Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.

         I had a plan.

         These meetings were attended by just about everybody who had anything to do with the patient.  They were held at school times so that most of the teaching staff could be present as well. These meetings also had a tendency to drag on as everybody seemed to have a lot to say about very little, a trait not just limited to psychiatrists but also seen in social workers, therapists, nurses, junior grade doctors, teachers and visiting professionals. People always seemed to have a lot to say on cases where there was the least progress. 

 ©2016 Am Ang Zhang 
         My personal view is that this was a sure sign of anarchy which had unfortunately drifted into our Health Service, encouraged in part by the numerous re-organisations that had gradually eroded the authority of the doctor. 

         Saul Wurman[4], an architect by training but also an author of business and tour books, famously wrote that meetings really do not always need to be an hour long. Why can it not be ten or twenty minutes?

         Could I achieve that?

         After briefly explaining to all the purpose of the meeting, I turned to Sammy, who still had the nasal feeding tube “Micropore’d[5]” securely and said, “What do you think?”

         “It is so unfair.  Now I shall not be able to go to Harvard.”

         It is generally perceived as a given that a U.K. citizen who has been Sectioned will not be able to use the Visa Waiver to visit the U.S. If that person then has to apply for a Visa, having been detained under the Mental Health Act must be a major hindrance, although I have never seen this applied in practice. One of my patients did have to cancel a horse trial trip to Kentucky because she was sectioned at the height of a manic episode.

         I did not know she had aspirations to get to Harvard but I was not surprised given what I already knew about mother.

         “Before I say anything else, can I ask you a few things?”
         “What? Sure!”
         “Do you smoke, drink, take Ecstasy or go out clubbing?”
         “No.  Why?”
         “Do you have piercings and tattoos on you?”
         “Tattoos—yuk!  Yes, I having my ears pierced. That is all.”
         “Do you like Pop music?”
         “No way. I play the violin and I like Bach and Bartok!”
         Everybody was attentive now.
         “Do you shoot heroin or smoke Cannabis?”
         “No way!”
         She was getting annoyed.
         “What about boys and sex?” I felt bad even to ask especially in front of her mother, who I thought would faint if we knew something she did not.
         “How can you even ask and in front of my parents? You know I don’t do things like that!”

         I can remember my own adolescence. I did not do any of those things either and I did not even have pierced ears.

         I then turned to the parents.  Mother was a history teacher at a famous private school in one of England’s most middle class town. She also spent a year at Harvard, hence Sammy’s ambition to follow her. Father was a prominent city lawyer.

         “You have always provided well for her, a good education, European and U.S. holidays, a comfortable home and expensive music lessons.”

         “We are fortunate enough to be able to do that. She is our only child.” Mother replied in a tone implying, “what’s wrong with that?”

         “And she has always been a bright child, strong willed and single minded. She passed her Grade 8 violin with distinction at 14 and could have become a musician. But she wanted to do International Studies.” Mother added.

         “So she always had her way.”
         “She has always got on with everything, studying and practising the violin. And she keeps a tidy bedroom!”
         A tidy bedroom! My goodness, everything was falling into place.
         “Sammy……”
         “Yes……”

         “You know what? You are the first adolescent I know that keeps a tidy bedroom, do not do drugs, do not drink, do not smoke and you do not do a load of other things I asked you about. You are by modern standards a FAILED adolescent!”
         Then I turned to the parents.
         “And you, FAILED parents!”
         “And we FAILED you. We failed you because we had to hide behind the law and force fed you.”
         Sammy said, “I can’t do all those things even if you make me.”
         Ah, the turning point.
         “No, don’t get me wrong. I don’t want you to either.”
         I then told her that I would like to take the tube off her despite lack of progress, or because of it.
         It simply had not worked.
         I wanted her to take over, do what she needed to do and I would decide in about ten days if I had to extend the Treatment Order.
         Forty five minutes. The meeting took forty five minutes as people had to present summaries of different reports, the details of which were irrelevant here.
         The battle was over. Sammy looked relaxed. Nobody was fighting her now. She was back in control.
         I took her off the Section as she started to put on weight and before long she was discharged. 

         We forget how easy it is to entrench. To entrench is a sure way to perpetuate a problem.

Thursday, August 15, 2019

Autism: Wrong & Right & Temple Grandin


Can wrong sometimes be right? A question I had to face in my years of practice in Child Psychiatry.




The Consult:

Dear Cockroach Catcher:
We are a bit stuck with this Autistic boy with unusual OCD symptoms.

The boy was born in the US of American mother and British father. Diagnosed Autistic Spectrum Disorder age 4 with OCD symptoms. Was sent to an institution at age 5 when parents separated and mother could not cope. Father managed to get him to England after 10 months. His obsessional symptoms got worse and amongst them the most difficult is that he can’t bear to wear any clothes which are not brand new. He checks the tag, feels the clothing and sniffs it to decide if he would wear it.

He is on Prozac 40mg, which has reduced the aggressive outbursts but not made any real inroads into the dressing problem……except that he has occasionally managed to wear used socks.

Nowhere else in medicine is “innovation” more appropriate than in Child Psychiatry!

My first thoughts were: Cheat!

Then perhaps: Collude!

Neither would be in NICE or any textbook.

Cheat: get father to keep all the clothes tags or write to companies to get a lot of them to tag on to his clothes so that they are like new.

That saves some money. Failing that steal the tags.

(I can't believe I said that)

Patients come first.

Collusion: because he could sniff and tell that the re-tagged clothes are not new we may have to get him to agree to the ritual of tagging clothes and folding them nicely. One of my autistic patients turned our session into a TV session. So collusion is a better way.

It is a pity that nowadays we cannot spend enough time with these patients to understand them. If I may venture further and suggest that the boy perhaps associated new clothing to the new life with his father and he wanted to keep it that way. Obsessional symptoms are essentially a defence in psychodynamic terms and until the child (autistic or otherwise) can be sure of his place at his new home he is going to keep his defences. 


So spend more time with him and you may well be surprised!

It is probably good he was not in an institution. That was what they nearly did to Temple Grandin. There is so much we can learn from her story. She too was nearly institutionalised. She famously created a cuddling machine for herself!

Innovation again.

Wrong may sometimes be right.

Let me know.







Temple Grandin:
 



Dr Temple Grandin has a unique ability to understand the animal mind - and she's convinced her skill is down to her autistic brain.

Temple believes she experiences life like an animal. Her emotions are much simpler than most people's and she feels constantly anxious. It's this struggle with overwhelming anxiety that led her to discover just how much she has in common with animals and, in particular, cows.
Using her ability to observe the world through an animal's eye, she has been able to make an enormous impact on animal welfare. Her greatest achievement has been in the area of slaughterhouses - she has fundamentally changed the way animals are held and slaughtered.
Today she's an associate professor of animal science, a best-selling author and the most famous autistic woman on the planet.

Temple Grandin Website:

Dr. Grandin didn't talk until she was three and a half years old, communicating her frustration instead by screaming, peeping, and humming. In 1950, she was diagnosed with autism and her parents were told she should be institutionalized. She tells her story of "groping her way from the far side of darkness" in her book Emergence: Labeled Autistic, a book which stunned the world because, until its publication, most professionals and parents assumed that an autism diagnosis was virtually a death sentence to achievement or productivity in life.


Autism posts: