What the Hell is Wrong with Jody Arias and Ariel Castro? On Cluster B Personality Disorders.

Before we can talk about personality disorders we have to define what a “personality trait” and a “personality” are. A personality trait is an established and enduring way of thinking about and of relating to the world around you. For example, a person who always looks at the downside of things has a pessimistic personality trait whereas a person who “sees the world through rose colored glasses,” to use the old cliché, has an optimistic personality trait. The combination of your personality traits = your personality. A person meets the criteria for having a personality disorder when they have personality traits (enduring ways of thinking about and relating to the world) that are dysfunctional enough to cause an impairment in their functioning in day-to-day life. A person who has weird personality traits, aka: eccentricities, only meets the clinical threshold for having a personality disorder when those personality traits actually start affecting how they relate to the world/people around them in a negative way.

Personality disorders come in three “flavors” or clusters: Clusters A, B, and C. People with Cluster A personality disorders tend to be “weird”: think of a heavily bearded hermit who lives in a cave (schizoid personality disorder), Willy Wonka from Charlie and the Chocolate Factory (schizotypal personality disorder), or the UFO abduction theory fanatics (paranoid personality disorder). People with Cluster C personality disorders are extreme worriers, pathologically clingy people, or pathologically anal retentive persons (avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder, respectively – note that obsessive-compulsive personality disorder is a completely separate disorder from OCD, they just have similar names). Okay, so that leaves Cluster B personality disorders, which is what we’re going to discuss today.

I personally refer to Cluster B personality disorders as the “predatory personality disorders,” but that’s just my personal terminology and not a widely accepted medical term. With that said, by the end of this article I think that you’ll agree with me. The classic Cluster B personality disorders are: antisocial personality disorder (aka: sociopaths, aka: psychopaths), borderline personality disorder, and narcissistic personality disorder. Some people also group histrionic personality disorder, which is a pretty self-explanatory disorder (they’re EXTREMELY histrionic, duh), but I’m not so sure that these folks really belong in the same category as the three classic Cluster B’s so let’s forget about them for now. One quick word on a common misconception before we delve any deeper: antisocial (sociopathic) does not = asocial (a loner who doesn’t like to associate with people – a Cluster A personality disorder).

Antisocial personality disorder classically presents as a criminal who takes advantage of other people, violating their rights and their personhood without remorse. Not surprisingly our prisons are full of sociopaths. Unlike the common perception of the “cold psychopath,” most people with antisocial personality disorder are extremely likable – this is what allows them to get close enough to people to take advantage of them and it is also what allows sociopaths to often get away with their crimes after they have been caught. Sociopaths have zero empathy for other people. When you see courtroom videos of people who have committed horrific crimes and then get enraged when they are sent to prison, guess what?, the reason the criminal is angry is because they really don’t believe that they did anything wrong. Other people are just objects of opportunity for someone with antisocial personality disorder. Don’t ever ask yourself “how could someone do that to another person?” when you’re dealing with a sociopath – taking advantage and abusing another person is the same in the mind of a sociopath as pounding the pavement with a pair of running shoes or wiping your feet off on a floor mat is to you.

Not all sociopaths end up in prison. High functioning sociopaths can and do integrate themselves into life, taking advantage of people and using their superior social skills of manipulation to keep out of trouble. Ariel Castro was a good example of a high functioning sociopath for over a decade, keeping girls/women as sex slaves in his home while working as a school bus driver. Ariel Castro’s extreme sexual sadism may also make him a good candidate for “sadistic personality disorder,” which is currently a topic of research and not an official medical diagnosis. Regardless, there is no doubt in my mind that he has antisocial personality disorder, a psychopathology for which there is no effective treatment (penitentiary “therapy” is society’s current way of “treating” these predators). Antisocial personality disorder generally starts off as “conduct disorder” in childhood and a history of torturing animals is a major red flag that a child may grow up to become a sociopath. The good news about sociopaths is that they tend to mellow with age – a raging sociopath at age 20 has a reasonably decent chance of “burning out” and becoming a more decent person in their 50s or 60s. Most sociopaths are males and, interestingly, being born with an extra Y chromosome (XYY instead of the normal XY) is a risk factor for developing this disorder – however, most sociopaths do not have an extra Y chromosome.

Narcissistic Personality disorder is to antisocial personality disorder as Bud Light is to Budweiser – most narcissists have some sociopathic traits and most sociopaths have some narcissistic traits so the two disorders are really a spectrum of a single dysfunction. Narcissists have an inferiority complex and they compensate for this by acting grandiose and by being self-absorbed. Like sociopaths, narcissists are charming and they have no empathy for other people, viewing others as objects to be used and to be manipulated. People with narcissistic personality disorder often select careers in which their future subordinates will have to treat them in a deferential, god-like manner. Narcissists feel right at home in the military (Yes, Sir! Right away, Sir!) and the profession of surgery is notorious for attracting narcissists into its ranks (think of a surgeon cursing at his operating room staff and throwing things at them – that doesn’t just occur in the world of fiction!).

Like narcissists, people with borderline personality disorder also usually have sociopathic traits. Whereas Cluster B (predatory) personality traits typically present in men as narcissism or as full blown sociopathy, the female manifestation is more typically borderline personality disorder. Like narcissists and sociopaths, borderlines have zero empathy for other people, are charming, and manipulate people (to them people = objects) to get what they want. The core pathology at the heart of borderline personality disorder is believed to be an EXTREME fear of rejection. Borderlines suck people into close relationships then start manipulating and abusing these people. The unfortunates who find themselves trapped in a relationship with a borderline are in for a rocky ride, to say the least! Borderlines engage in splitting behavior in which they see people as either angelically “good” or demonically “bad,” with no gray area in between. While new lovers start out in the “good” category, they always eventually let the borderline down in some way or another and end up in the “bad” category. And that’s when the abuse starts. So now the unfortunate target of the borderline is in a relationship with someone who hates them but who also refuses to let them go because they’re intensely afraid of abandonment.

Borderlines keep the people they are abusing in their lives by performing self-mutilation and suicidal gestures to “punish” their significant others, to get people to feel sorry for them, and to essentially force their victims to come back to them (“if you leave I’m going to kill myself!”) — sometimes borderlines screw up their suicidal gestures and accidentally really do commit suicide. In my opinion, and this is just from watching TV like the rest of you, Jodi Arias is a particularly nasty borderline who was so furious about being “abandoned” by her boyfriend that she killed him. Notice how manipulative Arias was (or attempted to be) on the witness stand and in her interviews with the press – classic borderline behavior. I actually was the witness to a murder, a murder that was discovered two hours before I was scheduled to get on the plane to begin my deployment to Iraq (talk about a lousy day), committed by a borderline who was enraged at her boyfriend for attempting to break off the relationship. She gunned him down and then killed herself and I got to listen to it happen. I also grew up in the house of an ‘off of the charts’ borderline who was also a sadistic child abuser. If you happen to be interested click on the book cover to “Intrusive Memory” to your right – I have to warn you that unless you grew up in Rwanda or Bosnia this book will probably disturb the hell out of you.

Jodi Arias and Ariel Castro are examples of an exceptionally cruel borderline and sociopath, respectively. Most borderlines would never think of murdering their significant others, instead contenting themselves with manipulating them and often with abusing their children. Similarly, most sociopathic gang members have no problem robbing people and occasionally murdering them but wouldn’t stoop to the level of enslaving girls in their basement. Borderline personality disorder may be treatable to a degree with intensive counseling but the verdict on this is very much still out. Most borderlines are functional people who live and work right alongside the rest of us – the “good news” being that most of their predatory behavior is usually directed at intimate family members and not at acquaintances, although there definitely are exceptions to this loose rule. Sociopaths and narcissists also live alongside us and they do not tend to discriminate, victimizing whoever is convenient. Be careful who you trust and seek help from the authorities, an attorney, or both if a predator is preying on you. It is, sadly, a dangerous world.

LEGAL DISCLAIMER: Ariel Castro is accused of the crimes described above but he has not been convicted in a court of law. Mr. Castro has pled “not guilty” to above said crimes and he is not guilty until convicted under the laws of The United States of America and the State of Ohio. Ms. Arias has been found guilty of murdering her former boyfriend, Travis Alexander. This article is not based on a medical evaluation of Mr. Castro or Ms. Arias and no doctor-patient relationship exists or is implied as existing between Dr. Noto (nom de plume) or either of the above said persons. Dr. Noto’s views are his own and they are presented for entertainment purposes only on www.leonardonoto.com. Dr. Noto’s views, as expressed on www.leonardonoto.com, do not necessarily reflect the views of any of his employers, past or present.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The Life of a Colonial FugitiveIntrusive MemoryMedical School 101The Cannabinoid Hypothesis

 

 

 

Breast Cancer: Q&A

Goodygoody62: What causes breast cancer?

The same thing that causes all other forms of cancer, genetic mutations (changes) that allow a clone of cells to escape the body’s normal control mechanisms and to grow unchecked. The reason that your brain, for instance, doesn’t keep growing and eventually spill out of your ears is that the body has genetically programmed “brakes” that tell cells/tissues/organs when to stop growing. Similarly, the body also has controls that tell different types of cells where to grow and where not to — this is the reason why you have a heart/heart cells in your chest but not in your big toe. Cancer cells escape these controls and essentially grow wherever the want, destroying other organs in the process by growing into their “living space, by stealing their food/the body’s fuel reserves, and by producing neurochemicals that are toxic to noncancerous cells in the body.

It generally takes several collective mutations in a single cell for it to become cancerous, probably 5-7 in most cases. These mutations occur randomly but environmental factors can speed up the rate of mutations and thus increase your risk of getting cancer. For example, smoking is a major risk factor for several cancers because the carcinogens in cigarette smoke increase the rate of mutations in the body’s tissue, especially in the mouth/throat, lungs, and the bladder. Similarly, age is a major risk factor for cancer because the longer you live the more time that the cells in your body have to develop mutations. Eventually, if you live long enough, some of these cells will develop into a cancer — we all probably eventually get cancer if we live long enough, most people just die of something else before a cancer gets them. Some people inherit a mutation or two at birth and thus already have a few of these mutations from the get go, making it much more likely that they will develop cancer early in life.

The good news is that the body’s immune system usually destroys cancerous cells — you have almost certainly had potentially cancerous cells in your body multiple times in your life but you didn’t know it because your immune system destroyed these cells before they could cause a problem. To become cancerous mutated cells must both escape the body’s growth control mechanisms and develop mutations that allow them to escape detection by the immune system — hence needing more than 1 mutation (probably 5-7 in most cases) to truly become a cancer. However, this assumes that the body’s immune system is functioning properly. People with severe immune deficiencies, such as people with HIV/AIDS or people who are on immunosuppressant drugs (e.g. kidney transplant patients) are much more prone to developing cancer.

Dr. Leonardo Noto Physician, Author, and Owner of “The Health and Medical Blog with a Personality (www.leonardonoto.com).”

Disclaimer: Always discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. The internet and self-education are great, but they don’t replace your doc!

The Next Worldwide Pandemic? H7N9 Influenza – New Strain of Flu With A 100% Mortality Rate!

Update: Hot off the press. The Centers for Disease Control now reports 126 confirmed cases of H7N9 in China. 1 person in 5 infected with this new strain of influenza have died of the infection, with the virus seeming to have a higher mortality in older persons (some flu viruses actually have higher mortality in the young, but this is rare). Person-to-person transmission has not been definitively shown but it is suspected in a minority of the cases — a troubling finding for a strain of influenza that now seems to have a 20% mortality rate. In a way viruses with a lower (but still high) mortality rate can actually be more dangerous than viruses with an extremely high mortality rate. Ebola has an 80-90% mortality rate; however, because the virus kills virtually all of it’s victims and kills them rapidly the disease has, fortunately, never caused more than a local outbreak. An influenza virus with a 20% mortality rate, if confirmed, that could spread from person-to-person (still unproven and hopefully not the case with H7N9) is a scary thought indeed.

The H1N1 “Spanish Flu” pandemic of 1918 killed more people than The First World War, so fears about influenza are not just media hype. Influenza usually causes you to feel lousy with fever, chills, myalgias (muscle pains), cough, and gastrointestinal symptoms (especially diarrhea). But a particularly nasty strain can be deadly and not just for the very young and the very old, but for adults in the primes of their lives too. One of the problems with the flu is that many people toss around the term “flu” to describe just about any viral illness. “24 hour flu” and “stomach flu” are common illnesses and nothing to get too worked-up about, but the problem is that neither of these illnesses are actually caused by the influenza virus. Instead, they are examples of people inappropriately tossing out the term “flu” to describe illnesses that are caused by other, less pathogenic viruses. Real influenza virus, especially when a nasty strain is in circulation, can be a really big deal and if you don’t believe me then visit the graves of one of the 30 million people who were killed by the Spanish Flu of 1918! As such, the emergence in China of a new and unique strain of flu, H7N9, that infected and killed three people in February and March of this year has perked up the ears of epidemiologist worldwide and for good reason – it may be the next global pandemic. While H7N9 is currently thought to pass only from birds to people, and not from people to people, that may not remain true for much longer and I’m going to explain why (hold on to your seats young Padawans, it’s going to be a bumpy ride!).

There are three main types of Influenza, conveniently named Influenza A, B, and C. Influenza B is primarily a human disease and it pops up from time-to-time and occasionally causes epidemics (localized outbreaks). Influenza C is almost entirely confined to animals. The type of influenza that causes pandemics (pandemic = a worldwide outbreaks of a disease) is influenza A and this tricky viruses lives in pigs, birds, and humans, loving to wreak havoc in the bodies of all of the above. Influenza A has two especially important viral proteins called hemagluttinin and neuraminidase and these two proteins are responsible for the naming of the different STRAINS of influenza A. There are 16 known types of the hemagluttinin protein and 9 known types of the neuraminidase protein. H1N1, the strain of influenza A responsible for the 2009 flu pandemic, has type-1 hemagluttinin and type-1 neuraminidase whereas H7N9 has type-7 hemaglutinin and type-9 neuraminidase. The combination of H7 and N9 has never been seen before and this means that nobody, including you, has acquired immunity to it — not a good situation!

So what’s the deal with these influenza viral proteins and why the heck do they matter? Hemagluttinin works by anchoring the flu virus to one of your body’s cells, a cell in your nose or in your lungs for instance, allowing the flu virus to penetrate into that cell. Once influenza is inside it hijacks the cell and forces it to make more influenza viruses, essentially turning your otherwise normal and well-behaving nose or lung cell into an influenza factory! Fresh off of the assembly line, these newly produced “baby” viruses then exit the hijacked factory cell using neuraminidase, breaking free to find new cells to infect and then repeating the cycle until before long your body is harboring a raging influenza infection.

 flu

Image: An artist’s rendition of an influenza virus. Viruses exist in the gray area between living and dead. They are capable of reproducing but only with the assistance (generally the involuntary assistance) of true cellular organisms. Viruses infect all forms of life from bacteria, to plants, to animals and humans.                        

The white blood cells of your body’s immune system use hemagluttinin and neuraminidase as a way to recognize the influenza virus and to destroy both the virus particles and the hijacked factory-cells that are producing new “baby” viruses. The problem is that influenza is constantly changing through both antigenic drift and antigenic shift into new forms that your body can’t recognize and that are therefore capable of causing a new infection, even if you’ve been infected with another strain of influenza before, even recently! Antigenic drift is the accumulation over time of minor mutations in preexisting subtypes of hemagluttinin and neuraminidase and this process is responsible for slowly producing new subtypes of these viral proteins over a period of years and decades. For example, originally there was probably only one type of hemagluttinin protein, H1 (let’s just assume it was H1, although H1 is actually just the first one that scientists discovered and it probably wasn’t really the first). Over years-to-decades H1 acquired enough mutations to form a hemaglutinin molecule that was different enough to deserve a new name, H2. This has happened at least 16 times since science has become advanced enough to monitor the process and that is the reason why there are 16 different subtypes of hemaglutinin, all of them potentially capable of producing a new pandemic strain of influenza.

While antigenic drift is a relatively lethargic process, antigenic shift is responsible for rapidly producing novel strains of influenza A and it is the process that produces the strains that are responsible for most influenza pandemics. Antigenic shift occurs when two strains of influenza – say H1N1 and H7N9 – both infect the same cell in, for example, a chicken. The protein subunits and the genetic material that code for them (the “blueprints” for the proteins) sometimes get mixed up and you end up with a cell that might produce H1N9 or H7N1, a novel strain of flu that no one has ever been exposed to. Because domestic pigs and chickens tend to live cramped and unsanitary conditions on farms, especially in developing countries, these animals are breeding factories for new strains of influenza. And since domestic pigs and chickens also live in close proximity to humans (farm workers), it doesn’t take much for a new strain of influenza to be born.

chickenpigs

Images: Domestic Chickens and Pigs in China: The source of most of history’s influenza pandemics. Note that the 2009 H1N1 pandemic was an exception in that it likely originated from a pig farm in Mexico.

Not all strains of influenza A infect are equally good at infecting birds, pigs, or humans – some prefer birds, some prefer pigs, and some prefer good ole’ mankind. But the problem is that influenza mutates (changes) rapidly so that a virus that only infects birds today may hop to humans tomorrow. Similarly, not all strains of influenza are terribly virulent (virulent essentially means capable of causing a nasty disease), some are  actually quite mild whereas others are truly horrible. Luckily the H1N1 strain of influenza A that caused the 2009 outbreak was mild (unless you were a pregnant woman, in which case it was highly fatal), but we won’t always be so lucky. Interestingly, most of the damage caused by influenza infection probably isn’t caused by the virus itself but rather by your body’s inflammatory response to it. When triggered by a particularly nasty strain of influenza, this inflammatory damage is a set up for acute respiratory distress syndrome – a disorder in which inflammatory damage to the lungs causes them to become flooded with fluid and generally dysfunctional. To add insult to the injury, widespread inflammatory lung damage provides an excellent “petri dish” for bacteria to grow in, making influenza victims highly susceptible to developing atypical pneumonias from bacteria that normally don’t grow in the lungs. Staph aureus pneumonia is particularly notorious for killing flu victims – staph aureus is the same bug that causes skin abscesses and it doesn’t take much of an imagination to picture what it would do to your fragile lungs!

Fortunately H7N9 doesn’t appear to pass from humans-to-humans, at least for now. All of the known cases of this disease have been attributed to humans being in close contact with infected animals, and thank goodness for that because all three of the people who are known to have been infected with H7N9 died of the disease. But like all strains of influenza H7N9 is constantly mutating, probably even as you read this article. No one can predict with certainty whether H7N9 will fully make the leap to humans and become a human-to-human transmissible disease. Yet history shows that the question is not when we will have another deadly flu pandemic, but when.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The Life of a Colonial FugitiveIntrusive Memory E-CoverMedical School 101The Cannabinoid Hypothesis

References

How the Influenza Virus Changes. http://www.cdc.gov/flu/about/viruses/change.htm. Accessed 23 MAY 2013.

Human Infection with a Novel Avian-Origin Influenza A (H7N9) Virus. The New England Journal of Medicine. Vol. 368 No. 20. 16 MAY 2013.

Images Courtesy of Wikipedia/Wikimedia Commons and Google Images.

Medicalese Deciphered – A Little Weekend Fun With Medical Lingo

42 y/o M c EtOHism admitted for R femur fx d/t MVA, s/p ORIF POD#3, now complaining of AVH and c HTN + tachycardia on vitals.

Translation:

42 year old male with alcoholism (EtOHism) admitted to the hospital for a right (R) femur (thigh bone) fracture caused by (due to) a motor vehicle accident (MVA—a car crash), status post (s/p) open reduction, internal fixation (ORIF), post-operative day (POD) #3, now complaining of audio-visual hallucinations (AVH) and also has high blood pressure (HTN—hypertension) and tachycardia that was detected during a vital sign check.

In a Nutshell:

This alcoholic got into a car wreck and broke his right thigh bone. The orthopedic surgeon (bone surgeon) took him to the operating room and performed an open reduction, internal fixation – a surgery that requires cutting open the patient’s thigh and/or hip, repositioning the broken thigh bone, and then hammering a rod into the soft marrow cavity of the bone that will act as a support strut for the bone as it heals (see the X-ray below). It is now three days from the operation and the patient is going into alcohol withdrawal, a potentially fatal condition that can cause hallucinations, high blood pressure, tachycardia (fast heart rate), and seizures. This post-operative sequel could have been avoided by monitoring the patient for signs of withdrawal more closely and by treating him with benzodiazepines, a group of medications that include Xanax, Klonopin, and Ativan and which are similar to alcohol in some respects (both alcohol and the benzodiazepines activate GABA receptors in the brain) and which are useful in both preventing and in treating alcohol withdrawal.

ORIF

18 y/o F c IDA, N/V/D, poor dentition, and amenorrhea x1yr. Pt BIBA to ED after parents found pt lying on the floor of the bathroom with AMS (mild) next to an empty bottle of MoM – suspect acute dehydration and underlying supratentorial etiology. BMI 18.

Translation:

18 year old female with iron deficiency anemia (IDA), nausea, vomiting, diarrhea (N/V/D), and one year of amenorrhea (lack of menstruation) who was brought in by ambulance (BIBA) to the emergency department after her parents found the patient (pt) lying on the floor of the bathroom next to a bottle of the laxative Milk of Magnesia (MoM). Apparently the patient was confused or acting strangely (mild AMS—altered mental status).  The doctor thinks that the patient is dehydrated due to her vomiting and diarrhea and that there is ultimately an underlying psychiatric etiology (cause) of her condition. The patient’s body mass index (BMI) is 18, which is very low (<20 = underweight; 20-25 is normal).

In a Nutshell:

This girl has an eating disorder. Her BMI of 18 suggests that she is anorexic (starves herself) while her purging behavior with laxatives suggests that she also has bulimic behavior (classically binging followed by purging, but sometimes just purging in anorexics who also have bulimic behavior). A lack of iron in the diet has caused this girl to develop iron deficiency anemia and her low BMI has resulted in hormonal abnormalities that have caused her to stop menstruating. Eating disorders are extremely serious and they are the psychiatric condition with the highest mortality. If you have an eating disorder your chance of dying from your disease if it is untreated is higher than the risk of death in even the most serious mood and psychotic disorders, e.g. bipolar disorder and schizophrenia. Unfortunately, some people with eating disorders consider this serious disease to be a “lifestyle choice”—shown below is a “Pro-Ana” bracelet in support of the anorexic lifestyle. It is common on pro-eating disorder websites for anorexia to be referred to as “my friend Ana” and for bulimia to be referred to as “my friend Mia.” Bulimics have a bracelet too by the way. Most people afflicted with eating disorders have both anorexic and bulimic behaviors, e.g. they usually have symptoms of both disorders.

red_ball_chain_bracelet_by_lutheranchick-d54mdc6[1]

21 y/o M with acute MDMA intox, admitted for GI pain 2/2 obstipation, now c BRBPR s/p self-removal of FB while being transported back from X-ray.

Translation:

21 year old male with acute MDMA (Ecstasy) intoxication, admitted for gastrointestinal (“stomach”) pain secondary to (2/2) obstipation (inability to pass gas or to have a bowel movement), now with bright red blood per rectum (BRBPR) status post (s/p) self-removal of a foreign body (FB) while being transported back from X-ray.

In a Nutshell:

This guy is high on ecstasy, stuck (or had stuck) a flashlight up his butt, and then had the great idea to yank it out while the poor ER staff was wheeling him back to his room after he got his X-ray. Now he’s bleeding and will probably need an exploratory surgery if the bleeding doesn’t stop on its own in the very near future. Rectal foreign bodies are very common in the emergency department—they are also a source of amusement for radiologists, who usually have a rather boring (albeit important) job. While rectal foreign bodies are embarrassing (don’t stick it up there, genius), they are also a serious medical problem and a potentially fatal cause of bowel obstruction and infection (due to disruption of the rectal /colon wall). If you ever have the misfortune of having this problem, go to the ER! Your doctor and the ER staff are required by law to keep their mouth shut about it and you can (and should) sue the heck out of them if they gossip (of course, the ideal way to prevent this problem is not to stick things up your butt).

CAVibrator

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The Life of a Colonial FugitiveIntrusive MemoryThe Cannabinoid HypothesisMedical School 101

References:

Open Reduction, Internal Fixation. Courtesy of Wikipedia. www.wikipedia.org.

Rectal Foreign Body. Courtesy of Wikimedia Commons. http://commons.wikimedia.org.

Pro-Ana Bracelet. Courtesy of the Producer (Open Source Image).

 

Life Support – What the Heck is it? The Layman’s Guide to Mechanical Ventilation and Critical Care Medicine.

The term “life support” has become so entrenched in the common jargon that people use it to refer to everything from the status of their failing relationship with a significant other to the condition of their old jalopy! Politicians fight over life support and whether or not we have the “right to die.” So what the heck is everyone, including probably you (even if you don’t know it), referring to when they utter those two dreadful words?

Let’s step back for a moment and briefly discuss breathing. You breathe for two reasons, to bring in oxygen so that the cells that make up your body can use it to “burn” fats and sugars for energy and to get rid of the toxic carbon dioxide that is produced as a by-product of this cellular metabolism (cellular “eating”). The diaphragm is a flat sheet of muscle that stretches across the bottom of your rib cage from front-to-back and that divides the abdominal cavity (“stomach”) from the chest cavity. The diaphragm is the primary muscle that powers breathing — when it moves down you inhale and when it relaxes and moves up you exhale.

Life support is more properly referred to as “mechanical ventilation” and a ventilator is simply a machine that breathes for someone who is unable to breathe for themselves. There are a lot of reasons why someone might not be able to breathe, and some of these reasons are temporary whereas others are permanent. People who overdose on narcotics often die because massive doses of narcotics depress your drive to breathe — once the narcotics are out of their system they start breathing again. A formerly common example of a reversible cause of respiratory failure (respiratory failure = you can’t breathe well-enough on your own to stay alive) was polio, a paralytic disease caused by the polio virus that has been eradicated from all of the world except Afghanistan, Pakistan, and Nigeria (due to anti-vaccination forces in those countries). Severe polio can weaken the body to such an extent that the polio victim stops breathing. Many lives were saved by the iron lung, the first mechanical ventilator (invented in the late 1800s and first widely used in the early to mid-1900s). These patient’s, most of whom were children, were kept alive by the iron lung for weeks-to-months until they finally recovered enough strength to breathe for themselves again, an amazing revolution in medicine because prior to the iron lung every single one of these people would have died!

The iron lung was an external respiratory and not very useful except for people with generally healthy lungs who couldn’t breathe temporarily because of some other cause, like the weakness caused by the polio virus or the temporary respiratory depression caused by narcotic overdosing. The iron lung was a negative pressure ventilator that created a vacuum around the patient. When the vacuum was turned up the patient’s chest rose and they sucked in air; when it was turned down the patient exhaled and then the cycle started over again. In the 1960s a truly revolutionary invention turned critical care medicine upside down and its head and back over again — positive pressure endotracheal intubation, the modern mechanical ventilator. Endotracheal ventilation involves sticking a breathing tube into a sedated or unconcious patient’s airway and then hooking it up to a machine that blows air into the patient’s lungs, a process that is roughly akin to using an airhose to inflate the tires on your car. The mechanical ventilator increases its air pressure to give the patient a breath and then decreases it to allow the patient to exhale (the chest is elastic and naturally exhales without really needing any assistance). This may not seem like a big deal, but look at the images of the iron lung versus endotracheal intubation and you can appreciate that it is possible to move (via a bed with wheels), operate on, and to examine a patient who is endotracheally ventilated — all of which are impractical or impossible in a patient who is being maintained on an iron lung. In addition, the superior and direct control of the airway pressures through the endotracheal ventilator allows the critical care doctor/pulmonologist to perform a lot of neat tricks (with pressures and mixes of inhaled gases) that can keep people with lousy lungs alive on the ventilator who would have died in the clunky old iron lung.

Iron Lung

Image 1: A patient in an iron lung.

Respiratory_therapist

Image 2: A patient on a positive pressure ventilator being ventilated through an endotracheal tube.

Endotracheal_tube_colored

Image 3: A diagram of endotracheal intubation. The tube is made of plastic and the balloon at the tip (“C”) seals the tube in place. Notice “D” — that is the esophagus, the tube that brings swallowed food into the stomach. It is a common and potentially deadly error to place an endotracheal tube in the esphagus instead of in the airway (the trachea).

***Factoid: If you’ve ever had general anesthesia for a surgical procedure you were intubated and kept alive on a mechanical ventilator! If you don’t remember it, well, that means that the anesthesia was working!!!***

An example of irreversible loss of the drive to breathe is a person who has suffered a massive head injuries — this unfortunate patient’s organs can often be kept alive with a mechanical ventilator, but since the brain is essentially destroyed and it is the brain that controls breathing, the minute you turn off the mechanical ventilator whatever tissues are still alive in the person’s body are going to die. The realization that you could keep a persons organs and tissues alive even when there was no chance of their brain recovering functioning (i.e. zero chance of them ever waking up) led to two important, albeit somewhat disturbing, changes in medicine. Before the invention of mechanical ventilation you died if you stopped breathing and your internal organs all died to within a few hours at most (some tissues die faster than other when they are cut off from oxygen — the brain and the heart die the fastest, within minutes, whereas skeletal muscle can take hours to complete the dying process). This led to the legal concept of brain death, which essentially is the determination that a person has suffered such a severe injury to their brain that they are unconscious and that they will never regain consciousness. Brain death is an important concept for two reasons, the first being that it doesn’t make any sense to keep everyone’s bodies alive after their brains are kaput — we’d have millions of people lying around on ventilators with zero chance of ever waking up if we did that and who would want that done to their body anyway, right. The second reason that brain death is important is that the overwhelming number of usable donor organs come from people who are brain dead — motorcycle accidents in people who aren’t wearing helmets are an especially common source of these organs because these accidents frequently kill the rider by destroying their brain and skull but leave the kidneys and liver intact and healthy enough to save another person’s life.

One Last Note: Patient’s in the ICU may also be treated with several other intensive therapies including powerful drugs to maintain their blood pressure, nutrition through a vein in patient’s who cannot eat for extended periods, and even with specialized pumps that are inserted into the aorta/heart to help it pump. But the cornerstone of critical care medicine is the mechanical ventilator and without mechanical ventilation modern critical care medicine would not be possible.

FYI: I’m having a promotional for the Kindle versions of all four of my books (click on the book covers) — all four books are $0.99 until May 15th!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The Life of a Colonial FugitiveIntrusive MemoryMedical School 101The Cannabinoid Hypothesis

References:

Medscape Today:

http://www.medscape.com/viewarticle/552178_2. Accessed 10 MAY 2013.

Images courtesy of

http://www.wikipedia.org. Accessed 10 MAY 2013. PPV Image courtesy of Rcp.basheer. ETT diagram courtesy of PhilippN.

The Medical Physiology of “Getting High” – How Narcotics and Other Drugs Work (Part 2/2)

FYI: All four of my books are on sale (Kindle versions are 99 cents; paperbacks are also on sale), so go click on one of those fancy bookcovers over their to your right! —->

As we discussed last time, most illegal “narcotics” aren’t really narcotics (opium derivatives) at all! As promised, here is a rundown of other common substances of abuse and how/why they produce euphoria (a “high”). Each of these substances is deserving of a full blog post and I’ll be doing that at some point in the future. But for now, here’s the basics – enjoy!

Before we get started, let’s discuss an important general principle of neurobiology, i.e. how your brain works! The thinking part of your noodle is made up of “neurons” (nerve cells). Neurons talk to each other by releasing “neurotransmitters,” which float across the tiny fluid-filled gaps that separate neurons and then bind to a receptor on another neuron. If “Neuron A” wants to tell “Neuron B” something it releases a “message” in the form of a neurotransmitter which then binds to a receptor (the “mailbox”) on “Neuron B.” This causes electrical activity in “Neuron B” and the aggregate of all of this neurotransmitter messaging and electrical activity is what results in your “brain waves” and in all of your thoughts and emotions! The words that you are seeing on this blog right now are the result of light entering your eyes and causing a cascade of neurotransmitter messaging and electrical signals that when added together in aggregate in the massively powerful, neuron-computer called your brain are reconstructed into the words and thoughts that you are experiencing right now! Drugs screw with this process by affecting the distribution of neurotransmitters in your noggin and different drugs affect different neurotransmitters, which is why smoking a nicotine-containing cigarette feels different than downing a beer.

One other quick note: Even though most drugs of abuse are potentially addictive, this is not true of all of them and even highly addictive drugs generally have far more occasional, recreational users than true addicts. Most drugs of abuse have a ratio of users-to-addicts of 10:1 – for the most addictive drugs, like nicotine and heroin, this ratio can be as low as 3:1, but that still probably a lot lower than most people realize.

Alcohol – The active ingredient in alcoholic beverages is ethanol, a substance which is often abbreviated in the medical records as “EtOH.” If a doctor writes that you’re an EtOHic in your chart, that means “alcoholic” my friend. As we discussed, mind-altering drugs work by either enhancing or inhibiting naturally occurring substances in the body called neurotransmitters. Ethanol is no exception to this rule and whiskey, beer, and Toothless Joe’s moonshine it makes you feel relaxed by potentiating the activity of GABA receptors. GABA receptors are the same neuroreceptors that are activated by benzodiazepines (e.g. Xanax) and barbiturates (e.g. phenobarbital). GABA is an inhibitory neurotransmitter that “relaxes” the activity of other neurons in the brain—this is why excessive ethanol consumption makes you feel REALLY relaxed, i.e. it puts you to sleep! Ethanol also inhibits the action of NMDA receptors, which are important for memory consolidation. By blocking NMDA receptors ethanol causes both memory impairment (“blackouts”) and mild dissociation (feeling detached from reality). An example of a more powerful NMDA antagonist (“inhibitor”) is PCP, which causes severe dissociation from reality and vivid hallucinations. Generally 1-2 drinks per day for a non-pregnant adult is considered to be a reasonable level of alcohol consumption and alcohol in moderation is good for your heart and probably also for your brain; however, if you’re drinking more than this you may have a problem and you should talk to your doc about it to see if you need help. Alcohol depresses your drive to breathe and this effect can be fatal when it is consumed with other respiratory depressants, especially narcotics, benzodiazepines, and barbiturates.

Benzodiazepines and Barbiturates: While we’re on the subject of GABA agonists (“agonist” = activates or enhances the effect of), let’s not forget barbiturates and benzodiazepines. Barbiturates are old drugs that were used for the treatment of anxiety back in the not-so-good old days when female doctors were still as rare as Texas steaks and when STDs were still treatable with penicillin. The problems with barbiturates are that they are addictive that it is really easy to fatally OD on them. Barbiturates are sometimes still used for people with severe seizure disorders and as a component of some powerful headache medications, but for the most part these dangerous drugs have been replaced by the benzodiazepines, a closely related class of GABA agonists that are much safer, albeit still addictive. The most famous benzodiazepines are Valium and Xanax, both of which are commonly used to treat anxiety disorders and which are commonly reported as the cause of fatal celebrity overdoses by the news media. While it is true that you can overdose on these medications, the reality is that overdosing on benzodiazepines alone is actually very hard to do and that the overwhelming majority of people who manage to kill themselves with benzos had also consumed another respiratory depressant (i.e. a drug that decreases your drive to breathe), usually alcohol, narcotics, or both. It just makes for a much better Nancy Grace or Fox News headline to say that “Pop Diva Z” overdosed on Xanax than to report that she overdosed on Bud Light, but the truth is usually both.

Nicotine: Smoking is the most common cause of preventable death in The United States and Marlboros, Camels, and Newports kill exponentially more Americans every year than all illegal drugs combined. Even alcohol, which wins the award for 1st runner up (mostly due to drunk driving and other accidents), doesn’t come even close to killing as many people as King Tobacco. Nicotine activates (surprise!) nicotinic receptors in the brain and its effects are incredibly complicated, resulting in neuro-cascades that act through just about every damn neurotransmitter that you can think of (dopamine, norepinephrine, serotonin, GABA, and more!). You may have noticed that “nicotine” conveniently binds to “nicotinic” receptors. The naming isn’t a coincidence – most neurotransmitters and their receptors were discovered by scientists who trying to figure out how the drugs on this list work! Tobacco is incredibly bad for you, especially when it is smoked, but nicotine does have a few beneficial effects including enhancing memory.

Marijuana: Speaking of a drug leading scientific discoveries, marijuana is responsible for the research that discovered what is probably the most numerous class of neuroreceptors in the human brain! THC, the active ingredient in marijuana (aka: cannabis) works by mimicking the endocannabinoids like anandamide that are naturally present in the brain and body. Endocannadinoids (and THC) activate cannabinoid receptors which serve to temporarily “slow down” the activity of neurons in the brain and spinal cord. Cannabinoids affect appetite and pain and they are medically useful for the treatment of both wasting disorders and probably for some chronic pain conditions as well. Marijuana causing the munchies and decreased perception of pain, “duh,” you say! But this is actually another common theme in medicine—the side-effects of drugs, both the legal and the illegal one, often alert attentive physicians and researchers to new potential uses of the drug. Cannabinoids are also useful anti-emetics (anti-vomiting drugs), which since chemotherapy can cause severe vomiting can be a useful property of cannabinoids for cancer patients. Unfortunately, cannabinoids also affect the cardiovascular system and increase the risk of heart attacks and probably also worsen high blood pressure in recreational users. Generally speaking, there is no clinically significant withdrawal following cannabis use/abuse because THC and its relatives are highly fat soluble and naturally taper out of the body—this is also the reason why heavy users of cannabis can test positive on a urinalysis several weeks (or even months) after their last use. The quote/unquote “amotivational syndrome” that has been attributed to cannabis is probably a side-effect of heavy recreational drug use in general rather than of cannabis in particular. The long term effects of smoking cannabis on lung health (cancer risk, etc.) are controversial but commonsense would tell you that inhaling any form of hot smoke into your lungs probably isn’t the greatest health decision.

Cocaine and Methamphetamine: Both of these drugs are stimulants and stimulant drugs work by enhancing the activity of the dopamine and norepinephrine pathways. Cocaine is a reuptake inhibitor of these neurotransmitters whereas amphetamines (including meth-) cause dopaminergic and noradrenergic neurons to release greater quantities of dopamine and norepinephrine—in other words, cocaine and amphetamines essentially have the same effect, they just produce that effect by somewhat different mechanisms. Cocaine is an interesting drug for several few reasons. First, it is the root drug for most topical anesthetics. The lidoCAINE and marCAINE that your doctor uses to numb the skin before stitching closed a skin wound are both derivatives of cocaine and lidocaine is also a powerful cardiac (heart) drug when it is injected. Cocaine is also notable because a lot of the doctors who performed pioneering work with this extremely important drug, including Sigmund Freud (the psychiatrist) and William Halsted (possibly the greatest surgeon who ever lived), became addicted to it. Before cocaine was purified by Western chemists it was chewed in the form of coca leaves by Native Americans in the Andes Mountains to produce a mild stimulants effect that many describe as similar to drinking a cup of coffee.

Cocaine and other stimulants are known as “sympathomimetics” because they activate the “sympathetic” division of the nervous system. To keep a long story short, there are two opposing components of the nervous system that are known as the sympathetic and the parasympathetic divisions (there are a lot of other parts to the nervous system too, but I’m only one dude writing this blog and I have a day job too…jeesh!). The sympathetic division is responsible for the “fight or flight” response that you get when you’re being chased by an angry dog or having an episode of stage fright while the parasympathetic division is responsible for calming you down (in part) and for mundane functions like digesting your food and what not. The nasty effects of cocaine and its cousins mostly stem from there powerful sympathetic/stimulant effects. When you’re being chased by that angry dog your heart starts pounding and your blood pressure shoots through the roof, both good things (temporarily) if your life is truly in danger but very bad things if you are using cocaine for fun, especially if you are a chronic user—a chronically elevated heart rate and high blood pressure are setups for heart attacks and strokes! The concurrent use of ethanol and cocaine also forms a metabolite that is directly toxic to your heart – so using both concomitantly, as most cocaine users do, is a really, really bad idea.

LSD: Is a hallucinogen that primarily exerts its effects by enhancing the actions of serotonin in your brain. Serotonin is the same neurotransmitter that is affected by the most commonly used class of antidepressants, the selective serotonin reuptake inhibitors (“SSRIs”), which include Paxil, Prozac, and Zoloft. LSD can cause flashbacks in heavy users and it has been known to cause severely disturbing “bad trips” (unpleasant/frightening hallucinations) in some people. Overall, the negative health side-effects of LSD are surprisingly scant given how powerful this drug is; however, LSD is produced in black market laboratories and sometimes these garage-chemists screw up and produce a chemical that can seriously hurt people. I aware of at least one case-series in which a bad batch of LSD caused permanent neurological disability (Parkinson’s disease symptoms) in users.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

AmazonIntrusive MemoryMedical School 101The Cannabinoid Hypothesis