Hacking Darwin by Jamie Metzl

What if during the stage of life that you will be planning a family, your doctor told you that it could be arranged so that your future child would have the best of yours and your partner’s genetic makeup? Isn’t that what everybody hopes for? Suppose it could also be arranged that your future child would not get cancer, diabetes and other serious illnesses and would lead a long and healthy life. In addition, you could choose for your offspring to have a very high IQ and great athletic ability? While you are at it, you could also choose to have this precious child have an outgoing, empathic personality.

The summer between college and medical school, I had a fellowship to work at the Jackson Memorial Laboratory in Bar Harbor, Maine. One of the projects that I worked on was to study the behavior differences between mice that differed from each other by one gene. Little did I realize that I was a small part of major scientific advances that were developing which are now on the verge of offering all of the above choices and much more.

This book explains what is happening in an exploding revolution in our understanding of the ability to manipulate human genetics. Initially, I felt the book was going to be too technical as even with my medical background, I had some trouble following the scientific descriptions of the splitting of the human genome. However, just as I was about to lose him, the author dialed back with a practical explanation and descriptions. He also was able to inject his sense of humor into the overwhelming implications of what he is talking about.

The result is an absolutely fascinating book that will completely change your view of Olympic athletes as well as the choices that you and your children may have to make when planning a family. I am sorry to say that reading this book make keep you awake at night contemplating the serious ethical and moral dilemmas that our society will now have to face. Thoughtfully, the author even offers some suggestions how we can grapple with those issues.

By the way, because of the background of the author Jamie Metzl, I can’t help wondering if he himself were genetically modified. He graduated Phi Beta Kappa from Brown University, held a PhD from Oxford and a law degree from Harvard Law School. In addition, he is an avid Ironman triathlete and an ultramarathoner.

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Todays book blog features a book which I had the pleasure of recently co-editing with my colleague Dr. James Strain. I have reproduced below the forward to the book written by Dr. Herbert Pardes.   The publisher has given me permission to offer the readers of this blog a 30 % discount for purchase of it if you use the code in the coupon at the end of the blog

Depression As A Systemic Illness – edited by James J, Strain, M.D. and Michael Blumenfield, M.D.

Forward to book- Written by Herbert Pardes, M.D.  ( Former Director of National Institute of Mental Health and former President of the American Psychiatric Association )

Depression occupies the minds and work of people of diverse disciplines. Prior to the introduction of anti-depressive treatments, depression was widely treated with interventions like electric-convulsive therapy (ECT). In the mid-1900s, the first monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs) were introduced. For decades subsequently, much research focused on such treatments. Depression was considered a mental disorder. The focus on these antidepressants was followed over the next five or six decades with few new developments.

This book stresses the breadth of the topic, describing depression as a systemic illness, not just a mental illness. The best thinking today is that there are new tools and concepts in research, awareness of multiple causes, multiple kinds of depression, and increasing recognition of the mechanics and physiology that produce them. The book creates an optimistic and innovative approach to understanding and treating depression.

Brain plasticity is remarkable. Much current focus has been on brain action. However, this text uniquely conceives of depression as systemic, resembling other non-psychiatric chronic illnesses such as diabetes, hypertension, asthma, congestive heart failure, etc.

New research techniques have generated a conviction that integrating diverse lines of research enhances the promise for advances in understanding the disorder of depression. Another conviction among depression experts is that clinicians and scientists should focus on earlier stages of the disorder. Early intervention appears to produce better outcomes. Also, there is a greater focus on the continuing effects of depression.

Brain plasticity and recognition of depression’s pervasive impact throughout the body—McEwen’s “allostatic load”—has induced scientists to examine enduring and long-term effects of depression. More depressive episodes and longer periods of depression appear to be correlated with more serious states of depression.

Contributory causes are multiple—genetics, family history, adverse childhood development, environmental stress, etc. Depression is highly heterogeneous. For example, when youth have persistent anxiety and/or depression as well as mental lability, subclinical mania, accompanied by parents with early-onset bipolar disease, 50% of such children also develop bipolar disease.

The systemic nature of depression with the many interconnections also results in omnipresent comorbidity. This new text explores, e.g., cancer, heart disease, and neurological disorders in this regard.

New treatment approaches being developed make use of neuroimaging, brain stimulation, and substances like ketamine. The latter produces rapid improvement in mood rating in patients resistant to typical antidepressants, but it may have a minimal lasting effect if not serially repeated; it is not as yet FDA-approved for depressive disorders.

There are five different types of transcranial medical stimulation (TMS). In some, TMS generates brain tissue regrowth over four- to six-week periods. Treatments like cognitive behavioral therapy work on circuits. Interpersonal therapy, too, is being used in creative ways in underdeveloped countries. One emphasis is looking for interventions that may foster synaptic plasticity and connections.

The enthusiasm of many scientists is palpable. Some assert that we are undergoing “a scientific revolution in mood disorder research is anticipated.” Encouraged by advances in cancer treatment through precision medicine, some foresee possible application of precision medicine to depression. The rich knowledge being developed from neuroimaging has led to “neuroimaging phenotypes,” which means an imaging picture shared widely by many depressed patients.

These developments are significant for education. The impact on training, the important role of primary health care professionals, the potential of psychoeducation are pertinent educational issues. Should primary care physicians not be able to diagnose and care for “garden variety” depressive disorders, and then, if necessary, refer refractory patients on to more experienced clinicians? Medical school curricula and residency training will need to be altered for non-psychiatric physicians to have sufficient skills to accomplish this.

Depression deserves recognition as an illness of major proportions. It affects vastly different body systems. The World Health Organization ranks it as exacting the greatest burden of illness on the world population. Innovative treatments and ideas provide optimism.

Considering it a systemic illness represents a change from the former perspective that brought patients with depression brief interludes of relief with ECT, psychotherapy, and/or drugs while ignoring the long-term course and its biological accompaniments. We deal with a longstanding illness that needs enduring attention. If treated early, and if one can modify the number, intensity, and length of episodes, we will be likely to produce improved outcomes.

This formulation of depression as a systemic illness, not just a mental illness, may also be welcomed, recognizing the many decades in which psychiatric illness and treatment suffered from stigma. Outstanding innovative leaders from many fields grasping the breadth of depression’s impact are working together, accumulating vast data and manifesting enthusiasm about possible major strides going forward.

This rich book brings experts together and covers extensively the biological, psychological, endocrinological, genetic, and imaging aspects of depression. This collaboration by outstanding scientists and clinicians represents probably our greatest hope for real improvement in the management of depression. It is well described here. While not minimizing how much has to be done, this is an uplifting book, given the excellence of its contributors and their laboratories, and the proliferation of new and imaginative tools and concepts to advance the effort to bring depression under control.

To purchase this book directly from Oxford University Press at a 30% discount please follow the directions in the discount coupon above and use the promo code in that coupon or note this code ” AMPROMD9 “and click here

To purchase Psychosomatics a text book edited by Dr. Michael Blumenfield and Dr. James Strain please click here

To purchase Psychosomatic Medicine ( 2nd edition) a text book written by Dr. Michael Blumenfield and Dr. Maria Tiamson please click here 

To purchase Intervention and Resilience After Mass Trauma a text book  edited by Dr. Michael Blumenfield and Dr. Robert Ursano please click here

To purchase Psychological Care of the Burn and Trauma Patient  a text book written by Dr. Michael Blumenfield and Ms. Margot Schoeps please click here 

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Moving On – A Life by Oliver Sacks

I never read any of his books other than this biography. I read about many of them. I don’t recall hearing him speak in person although I believe I attended one of his lectures at the American Psychiatric Association meeting. I was familiar with many of the places that he spoke about in New York, San Francisco and Los Angeles and I even had some friends and colleagues who knew his analyst, David Shengold. Although I was never anywhere near being in his league as a clinician, writer and brilliant mind, his areas of interest had always fascinated me. So I guess you can say in reading this book, I had a certain amount of kinship and empathy for him although in many ways he was miles apart from my world.

He was born in England to a Jewish family. Two of his cousins were Al Capp, the famous cartoonist and Abba Eden, a famed Israeli Prime Minister. One of his brothers was schizophrenic and we can’t help wondering if his desire to crack the code on the workings of the brain may have had its origin with that experience. Both his parents were physicians and he has early memories of hearing them discuss interesting cases. His father thought it was a shame when a case  was written up in the popular press but his mother was a great storyteller. No doubt it was at his parent’s knee that he became fascinated by case histories.

The reader of this book will benefit by his ability to tell good stories. At times he jumps around and he may lose you with the exact time sequence but that will be a small price to pay for an interesting story of a brilliant man who led his life, well lived, his way.

It was his misfortune to be born gay at a time when it was considered to be a choice, rather than an inborn destiny that we know it is today. It is sad to hear that after he had his first sexual experience, he had none for the next 35 years. It was heartwarming to see that he fell in love and was able to live a happy intimate life with a man in the twilight of his life.

In a small way, I could relate to his early fascination with the working of the brain and the scientific advances that were occurring, as he was completing medical school and making the decision to become a neurologist. This was approximately the time that I was in college in the late 1950s. I had participated in a special project where we implanted electrodes into the brain of a cat, in which we could then record after the cat had recovered from surgery and resumed it’s relatively normal life. There were situations where we could tell in advance when the cat was going to make a decision, based on the brain waves before the cat made them. It was very tempting for me because of this experience to want to choose a career in neurology but for me, clinical psychiatry beckoned and that became the direction that I took. We are all fortunate that Dr. Sacks followed his interest in the workings of the brain.

When Dr. Sacks came to the United States, he was in his ‘20s and his first stop was San Francisco where he became an intern at Mount Zion Hospital. Not only was this young doctor quite fearless on his motorcycle but he was also fearless in his self-experimentation with LSD, PCP, later known as Angel Dust and who knows what else. I am sure his experience with mind altering drugs at this time paved the way to his lifelong study of the brain and the workings of the mind.

He dropped a tidbit taking place during this time period about how he got out of the draft. I know firsthand that young doctors were subject to being drafted into the military during both the Korean War and the Vietnam War. It was in 1968 that he said that he persuaded the draft board that he was not suitable material for the draft. I wonder what this was all about.

As someone who has worked in academia, I was particularly interested in what he had to say about one of his first jobs working in a clinical research lab. He reports that on his own, he made observations that he felt merited a write-up for a journal. When he wrote his first paper and it was accepted for publication, his boss was furious and fired him and then according to Dr. Sacks used some of his data which the boss claimed was his own for another publication. I have seen similar situations where there is conflict between the young person and the father figure. I can’t help wondering what would have happened if Sacks had tried to collaborate with his boss. In later years, he described getting along well with his colleagues and sharing data and theories but on the other hand, there seems to be a certain lone wolf quality and approach to his ultimate final products. I really can’t say if he was generous in allowing co-authorships with younger colleagues when he was the famous established author.

His life in Southern California was particularly fun to read about, since he had a house in Topanga Canyon, which is near the area where I now live. He reports zooming around on his motorcycle and it was obviously quite different than it is now, trying to get around on the busy freeway. He reports that he became the doctor of sorts to the Hells Angels, as well as being a Venice Beach bodybuilder.

He really seemed to come into his own once he came to New York. One might have expected him to join the full time faculty at one of the many outstanding medical schools. Instead, he decided to become the peripatetic neurologist by being a consultant to the Beth Abraham Nursing Home , the Little Sisters Nursing Home, both known as “ Manors,” among other places. It was here that he made his groundbreaking observation on post encephalitic patients who received L-DOPA and have their “Awakenings,” often temporary but revealing great insight into the workings of the brain.

His book, by the same name became a New York Times bestseller for 26 weeks and was made into a screenplay by Harold Pinter and into a great movie in which he was played by Robin Williams. This was followed by a number of other world famous books such as The Man Who Mistook His Wife For His Hat, Hallucinations and many others

In his heart and soul, it was clear that he was a storyteller. His understanding of neurology allowed him to listen and observe his patients and make insights that were not only fascinating but were important scientific advances for his time. He was also able to educate the public with his ability to write and make his case histories come alive as real people with unusual problems. He was unbelievably prolific and accumulated thousands of diaries filled with observations of his patients and of the people that he met and interacted with. He became friends and corresponded with some of the great minds of his time, such as Francis Crick (of  the DNA guys Watson and Crick) and Stephen Jay Gould as well as Gerry Edelman, author of the groundbreaking book, Neural Darwinism which Sacks explains in great detail in the biography.

Although I don’t think he mentioned it his book, I read elsewhere and that some of the subjects of his writings didn’t like that they were described in a manner in which t they could be recognized. Perhaps he didn’t get what we now call “informed consent.” He obviously wrote because of his love of the subjects he wrote about as well as because of the love that he had for these people whom he got to know.

One of the most important subjects of his writings that he definitely had permission to write about was himself. When he severely injured his leg, he was able to write a book titled A Leg to Stand On. In his waning years, he developed a melanoma in his retina. This stimulated him to enlarge upon his earlier observations about vision and consciousness. No doubt , he developed a personal attachment to the people he wrote about but he seemed to be also writing for the personal gratification and acceptance of himself and his works. He related a situation where due to one of his books receiving bad reviews, he went through 3 months of being severely depressed .

Oliver Sacks certainly lived his life to the fullest, He received much recognition for his work. He was also recognized by the Queen of England and honored with the designation of Commander. Not only did he receive much satisfaction from his many accomplishments, but he was able to share so much of his thought process and insights with the people who read his papers and books. He passed away a few months ago (August 2015) but I’m sure that his stories and observations will live on for many generations.

My Sister’s Keeper by Jodi Picoult – This was the second Jodi Picolt novel which I had the pleasure of reading. The first was The Storyteller, which was about the granddaughter of a holocaust survivor who finds herself friends with a former Nazi Concentration Camp guard who killed many prisoners in the same camp where her grandmother was imprisoned. The elderly ill Nazi asks the grown granddaughter to hasten his death. Picoult obviously has the ability to extract the ethical issues which can go to the heart and soul of our humanity. In My Sister’s Keeper a child develops a potentially fatal disease, which is unresponsive to various treatments. Blood transfusions, bone marrow transplant and ultimately a kidney transplant would be necessary to keep her alive. Things look bad for survival, as treatment options appear to be running out. The parents and brother don’t have the right “match” to be useful and a search for the right donor seems futile. However, it is possible for anther sibling, not yet conceived, to be the right match especially if there are genetic manipulation performed which would choose the right embryo – a type of carefully selected artificial insemination using the biological parents. It works out great and the parents see the stem cells from the umbilical cord of the newly born child, which would normally be thrown away being transferred to their ill daughter. On subsequent occasions when there is a relapse, there can be blood transfusions from the younger sister. Even a bone marrow transplant would be life saving.

The majority of the book takes place after Anna the younger sister now 13, has decided to visit an attorney, Campbell Chance and request that she be allowed to make her own decisions on what part of her body is given to her sister. In other words, she wants to be medically emancipated. The author gets into the head of each character as each chapter is written in the voice of one the important players in this real life drama. Katie is the older sister who has been sick most of her life and yet feels close to younger sister who is now resisting giving her what she needs to live. Jesse is the brother who in response to the emotional turmoil in the family becomes a juvenile delighquent and somewhat of a pyromaniac. Brian is the father who happens to be a brave fireman and a caring, loving father to all three of his children. Sara is the mother who clearly would do anything to save her daughter. She happens to be an attorney and it seemed natural to her that when there was going to be a trial to determine if the younger daughter is to be free to make her own decision, she will defend the parent’s point of view that they can make the decisions for Anna. Campbell is the attorney who Anna has chosen to represent her. It turns out that his personal story informs us of another aspect of the dilemma as do the the feelings and experience of Julie, the woman who is chosen by the court to be the guardian ad litem for Anna By providing us with riveting insight into each of these people, the reader is swept up as if we are living through this painful scenario.

Life of course is filled with potential heartaches, which we all must experience, but to varying degrees and at different times Even though we know about the disappointments of life, illness and death that may be around the corner, rarely are there things that we have never heard about. The situation of expecting one child to dedicate and perhaps risk her life to possibly save the life and maintain the well being of a sibling is quite unique. While not exactly the same, it reminds me of Sophie’s Choice. Should the author give us a happy ending or any ending in fact, is an interesting question. Ms. Picoult certainly did not shy away by leaving the ending to our imagination, which a lesser author may have done. We are challenged to think through the horns of this ethical dilemma. We make choices in our mind but we are able to see the where they are going in this story and perhaps in the future with modern technology.

5 Days at Memorial: Life and Death in a Storm Ravaged Hospital by Sheri Fink – This is a great book for anyone who works in a hospital especially doctors and nurses who realize they could be on call when a disaster might strike. Also include yourself in this group if you are a  hospital administrator or someone who likes to wrestle with ethical dilemmas. Be prepared for a lot of repetition, medical details that may all seem to be almost the same to most people as well as for some dips into the history of this hospital, other disasters and a course in ethics over the years even dating back to ancient times. If you can handle all of this, you really have an exciting, intellectually stimulating book with a look at disaster medicine, making medical and ethical decisions under difficult circumstances and some good legal battles. The main event was the 2005 Hurricane Katrina, which was the costliest natural disaster, as well as one of the five deadliest hurricanes in the history of the United States. At least 1,833 people died in the hurricane and subsequent floods. This book deals with the impact of the storm on Memorial Hospital in New Orleans, which was a 312-bed hospital, which included patients receiving intensive care and a larger section of the hospital where critically ill patients were treated. As the floodwater rose, most of the power in the hospital was irretrievably lost. There was no sanitation, and they were running out of food. Indoor temperatures were as high as 110 F degrees. At one point there were over 2000 people in the hospital as the numbers swelled with families of patients and staff as well as refugees from the surrounding city. The hospital became surrounded by water and there was no way to leave by car. A makeshift helipad was established on the roof but to get there patients, had to be carried up several flights of stairs usually in the dark and passed through a hole in the wall to get to another part of the hospital complex and up additional stairs. There was limited oxygen for these patients and for some the nurses had to squeeze a balloon like device to get the air into their lungs and drip an IV into their veins while going up the stairs. It was difficult getting enough helicopters to remove all the people from the hospital. Decisions had to be made which patients to evacuate first. Should it be the ones that were barely alive and wouldn’t be expected to even survive the trip to another location or perhaps already had a fatal illness where their demise was expected in a few days or should the patients go first who had a better long term outlook but still required hospital care?? Should the preference or order of care be influenced if the patient had a DNR order, meaning do not resuscitate the patient if their heart stops or if they stop breathing. As the first three or four days passed most of the people were evacuated (where they were evacuated to was another problem). There was confusion and questions about the actions by the corporation that owned the hospital and what arrangements they were making to help the stranded hospital’s need for evacuation. Outside the hospital gunshots were heard and there were concerns that looters might enter the hospital by boat. There was a concern about the physical integrity of the old hospital walls. You would think that the National Guard and the US Government should have done a heroic operation to save everyone from the beginning. They apparently were saving people from rooftops of their homes, helping out in the Superdome, which was the place of last resort for the people of New Orleans who weren’t able to escape before the flood, as well as sporadically appearing on the helicopter pad.  In the end there were a small number of doctors and nurses trying to care for the remaining and sickest patients. There was concern that even moving some of them would be fatal. One man was so obese that they couldn’t figure out how to move him. Some patients were clearly in the last hours hours of their lives. Others would soon be that way if they didn’t get more intensive care. One of the remaining doctors along with two nurses was Dr. Anna Pous, a very compassionate and brilliant ENT surgeon who had a history of reconstructing patients with advanced cancer. She found herself faced with the task of trying to relieve the suffering of several remaining patients. It is well known to physicians and nurses who treat dying patients, that morphine often in combination with a rapid acting tranquillizer such as Versed, given intravenous will relieve the pain and agonizing difficulty breathing in the final stages of life. It is also known that this treatment could hasten their demise. Dr. Pous appeared to have made the decision to have several patients receive large doses of morphine and Versed, which would painlessly end their lives. At a  later point in time , this action was felt by some people to be murder. In fact, Dr. Pous  was actually arrested, handcuffed and was with two nurses charged with second-degree murder. The response of the medical community from this hospital and from across the country, the legal and emotional reactions of some of the patient’s families, the media hype and the ethical questions which were being asked, were an important part of this book. The book provides few answers and lots of stimulating questions. The author won a Pulitzer Prize for her reporting on this subject in the New York Times Magazine. If you are drawn to this subject you will not be disappointed. 

Over the Waterfall by Marilyn Martone- This book was given to me by my cousin who is a rehabilitation counselor and social worker case manager and is mentioned in the book  as being some assistance to the author and her daughter. The book is brought about because of a tragic accident in which Michelle, the 21-year-old daughter of the author, was hit by a car and suffered a terrible traumatic brain injury. In one split second a vibrant, brilliant college student was put into a coma, which lasted for months, which would be followed by a very slow and gradual improvement which meant that her life and the life of her family would never be the same. The author and mother brought a unique perspective to this life-changing event , in that she has a master’s degree in health-care ethics and a PhD in moral theology. She had taught classes concerning how to deal with people and their families who had loved ones in coma and had been faced with making critical decisions. Despite this background she was not prepared for how this would impact upon her. She never imagined the role she would play by being at her daughter’s bedside frequently for the most of the day and night for months at a time and of the admissions to several different hospitals. She had to deal with a range of problems and decisions which included having to sign consents without knowing if it were really the best thing for her daughter, seeing doctors , nurses and hospitals make mistakes which she was able to catch, knowing the best nursing techniques that the staff would frequently not know, figuring out how to navigate the desire of the hospital to discharge her daughter to lower level of care for economic reasons etc. Most important to her was her mission to make sure the hospital staff viewed her daughter as the person she was rather than the case with the specific injuries. I am no stranger to medical and surgical settings in a hospital, which ranged from critical care to rehabilitation. For many years I was a psychiatric consultant to a large hospital , which was also a trauma and burn center. While I have seen many of the issues that are discussed in this book in a variety of different patients, I have never had the opportunity to appreciate how it could impact one person over a considerable period of time. This soft covered, self published book is 203 pages and it flows easily. In the end we don’t know the extent of the residual damage to her daughter but do know that she is on a path of constantly improving. We do know something about the human spirit, faith and the dedication of the mother and family of Michelle. Having shared part of this major journey with the author, we also have much more insight into what is involved for the family and how their lives were changed. If we are healthcare workers , we certainly are the richer for the insight provided to us. We all will come away from this book with greater empathy for anyone who must go through this ordeal.

Ido in Autismland by Ido Kedar – Although I am not an expert in this area, I believe that this will be a landmark book for families, educators and any professionals who work with young people with autism. It is a book of short essays written by a 15 year old about his experience with his condition starting with some pieces written when he was 12 years old.

What is unusual, unique and very important about this author is that he cannot speak and only when he was about 11 years old did he begin to communicate by pointing to letters on a letter board. Up to that point no one had any idea that he was an above average intelligent kid who began to read when he was about three years old.He was terribly frustrated by being treated by well meaning experts in autism and education by drilling him on simple exercises meant for a three year old child who was having trouble learning. He was asked to point to his nose which he often could not do and was judged accordingly.  Even when he began to point to letters and make intelligent sentences, just about everyone thought that his mother was guiding his hand since she had to steady it for him to point. It took his father, who is a scientist, two more years before he was convinced that his son was truly communicating fully formed intelligent sentences. The problem would seem to be that he could not control his body. He often would have great difficulty even signaling that he could make even  simple calculations or understood basic concepts.  This was further complicated by his arm flapping which would occur when he was anxious which he referred to as “stims“ . Other times he would do unexplainable pieces of behavior such as pulling his Mom’s hair or that of beloved aide when he was frustrated or embarrassed. This pattern of behavior is common in many children who fall under the rubric of autism except they are usually not recognized to understand things and mainly have trouble in controlling their bodies to communicate. Instead they are often deemed “retarded” and/or  “developmentally handicapped.”

Ido believes that he is not “one in a million” and that he has had indication that many of his friends with non verbal autism are as frustrated as he used to be. Once Ido proved he could communicate with a letter board and then on the keys of a computer, a new world opened up to him. He was put in mainstream classes which he would attend with an aide and has entered high school with the aspiration to go to college. It is a constant uphill battle, as while the administrators of his middle school were very supportive, he found that was not the case of the first high school which he entered. Obviously, it did takes a great deal of resources and some special accommodation to allow him to function in a regular high school environment. After transferring to a second high school he seemed to be quite adjusted as he continues forth.

This book traces his progress as well as clarifying many of his characteristics and experiences. For example he sees people in different colors such as red blue, yellow etc. which are related to their emotional state perhaps in relationship to himself. He is also  is very sensitive to sound and appears to have very keen hearing . He therefore at times gets overwhelmed by loud noises, certain music. being in the presence of multiple people talking . These and other situations can cause him to have what would appear to be overwhelming panic attacks. This is not only experienced as severe anxiety but it intensifies uncontrolled movements of his body. Over the years he has found that various types of physical training and exercise actually improved his self control, something that was not initially recognized as it was neglected in any attempts to assist him.

I found it interesting, as a psychiatrist,  that he did not mention whether or not he was given a trial on any anti-anxiety and anti-panic medications which are believed to directly  effect various pathways in the brain which are involved when people have such overwhelming emotions. I would imagine that the medical experts in this field have evaluated the  effect of such drugs as an adjunct to his treatment program but if they have not, it certainly should be done.

Ido frequently mentions that he knows that he has an illness that places many limitations on him but he prefers to focus on what he can do and what he hopes to be able to do in the future. He also is dedicated to teaching the public as well as families of children with autism and experts about the potential of people like himself.   Ido would probably say “ so called experts” since he has a sense of humor and he is keenly aware of how so many experts have misinterpreted his abilities). Not only is he becoming an advocate but he must be also considered to be a hero for so many people who are locked in the land of autism.

For a view of brief video clip of Ido at a meeting as one of his speeches is read go to:  http://www.youtube.com/watch?v=V4VR1KYRX8s

Handbook of AIDS Psychiatry by Mary Ann Cohen, Harold W. Goforth, Joseph Z. Lux, Sharon M. Batista, Sami Khalife, Kelly L. Cozza and Jocelyn Soffer, Oxford University Press, New York, 2010, 384pp, $49.95

Book Review originally written for and published in  the Journal of the American Academy of  Psychoanalysis and Dynamic Psychiatry

It is unusual for the Book Review Editor of this journal to request a review about a book that does not have psychoanalytic theory, dynamic psychiatry or the application of these ideas, as it’s main thesis. This book, which is about all aspects of AIDS, is such an exception. It is fitting that it be presented to the readers of this journal since this disease, more than any other modern day medical condition has impacted all aspects of psychiatry and mental health. Those of us who were practicing in the early 1980s, especially if you were doing hospital consultations, first saw this become known as a mysterious disease with dark spots on skin that was universally fatal. It then became associated with homosexuals and drug addicts The disease was believed to be highly contagious and caused by blood and sexual transmission. Medical personal became fearful of contracting the disease from patients. An accidental  needle stick while drawing blood or being nicked with a scalpel during surgery, which once was an inconvenience, now became a potentially fatal event. The disease weakened the immune system  and could lead to  deadly opportunistic infections. It ultimately was identified as being caused by the Human Immunodeficiency Virus (HIV). From it’s discovery in 1981 to 2006 AIDS killed more than 25 million people and is still counting.

Not only did psychiatrists and mental health professional see the impact of this disease in our hospital work but those of us doing outpatient psychotherapy could not help but appreciate the effect of this pandemic on many of our patients. Homophobias, which could be multidetermined at any point in time, became greatly exaggerated because of fears of contamination from AIDS. There was a reexamination of all sexual behavior as people began to realize that heterosexual transmission of this disease was also a reality. Questions were being raised whether couples should exchange HIV testing results before engaging in sexual relations? Then there was the realization that AIDS was devastating the gay and bisexual community. We saw a grieving response that extended beyond immediate close friend and families. People throughout the country visited exhibits of  traveling AIDS quilts with patches made as a memorial to individual patients. There were forensic issues encountered by some of our colleagues where people were acting out their anger about being HIV positive by having unprotected sex . There were discussions among therapists of how to deal with a patient whom they  knew was HIV positive but was not telling his or her partners.

The NIH and the NIMH awarded huge amounts of grant money directed towards AIDS and HIV research in the past 25-30 years. As a result many of the psychiatrists practicing today were supported by these grants at some time in their career or were trained by people who had such support and were well oriented about the psychiatric and psychological aspects of AIDS.

All of this is what makes this 2010 first edition of the Handbook of AIDS Psychiatry such a valuable book. Psychiatrist Mary Ann Cohen, a pioneer in the AIDS field and her six outstanding colleagues have written a book, which includes just about everything we should or might want to know about HIV and AIDS. It is billed as a practical book, which it is, but it is also a definitive work on this subject with over 1500 references. Some of the chapters are adapted from an earlier book titled Comprehensive Textbook of AIDS Psychiatry edited by Drs. Mary Ann Cohen and Jack Gorman, published in 2008 also by Oxford. Seven of the contributors to the earlier work took on the task of developing this current book.

This is not an edited book. All the 14 chapters are written by some combination of the seven authors. Dr. Cohen was involved in all but two of the chapters. Drs. Battista and Soffer were listed as residents at the time the book was published. The first 13 chapters were each followed by multiple pages of references and the final chapter on resources had addresses, phone numbers and web sites.

The widespread imprint of this disease and the comprehensive approach of this book is illustrated in the first chapter where the authors lay out the setting and models of AIDS psychiatric care. They start with effective parenting and prevention of early childhood trauma and conclude with the sections on education, HIV testing, condom distribution, rehabilitation centers, chronic care facilities and nursing homes. They touch upon the prejudice and discrimination labeled as AIDSism which unfortunately is ubiquitous and is also discussed in other chapters in the book.

Chapters titled Biopsychosocial Approach and HIV Through The Life Cycle cover material with which a psychiatrist trained in the past twenty-five years should be quite familiar. However the authors are not content with just reminding the reader to take a comprehensive history in areas relevant to this disease, but they offer over 100 suggested questions in doing a sexual history, suicide evaluation, substance abuse history or a violence evaluation. The following are examples of a few questions, which you may not have thought to use:

1. (Taking a sexual history) How do your cultural beliefs affect your sexuality?

2- Are you aware that petroleum-based lubricants (Vaseline and others) can cause leakage of condoms?

3- (To an LGBT person) What words do you prefer to describe your sexual identity?

4- (Evaluating suicidality) Do you plan to rejoin someone you lost?

5- (Taking a substance abuse history) What led to your first trying (the specific substance or substances)?

6- What effect did it have on the problem, crisis, or trauma in your life?

While it is stated that little is known about the relationship between aging and manifestations of psychiatric disorders in HIV positive persons, the discussion and questions raised about this topic in these chapters seem particularly important as treatment is now allowing people with AIDS to become senior citizens.

In the chapter titled Psychotherapeutic Treatment of Psychiatric Disorders it was noted that the enhanced understanding of the conflicts and struggles of the HIV positive  patient afforded by psychodynamic psychotherapy  has been described by multiple authors. This modality of treatment may be especially suited for patients with a trauma history as physical changes in the body and relationship stresses can awaken conflicts triggered by early trauma and neglect. This history of childhood emotional, physical and sexual trauma as well as neglect is also reported to be associated with risk behaviors and is prevalent in persons with HIV.  Other major themes, which were identified, that could surface in psychodynamic work include fears about mortality with the erosion of defensive denial as the illness progresses and conflicts surrounding sexuality. There also was a review of interpersonal psychotherapy, CBT, spiritual focused care, and various group therapy formats.

The chapters on psychiatric aspects of  stigma of HIV/ AIDS  will also be of  particular interest to the readers of this journal who are usually quite involved in dealing with subtle nuances in psychotherapy. Victim blaming, addict phobia and homophobia also called heterosexism are discussed in this context. While clinicians usually don’t have any trouble identifying stigma when they see it, there are scales which can be administered in both research protocols and clinical settings.

Dr. Cozza is the lead author in the chapter concerned with psychopharmacologic treatment issues. It is the longest chapter in the book and can best be summarized by their conclusion that the prescribing of psychotropic or any other class of medications to HIV positive patients taking ART is a complicated undertaking. The chapter provides an explanation of this statement in a narrative style as well as with some detailed tables showing the propensities of various medications to cause inhibition and induction.

Although psychiatrists are usually not involved with the treatment of physical symptoms or the actual administration of therapeutic drugs for  medical conditions, if they work with patients with AIDS they will be discussing various symptoms and complications. Dr. Goforth and Cohen put together two chapters which clearly explain symptoms of AIDS, as well as the medical illnesses associated with them. They review fatigue, sleep disorders, appetite problems, nausea and vomiting with a complete differential diagnosis and intervention options. The full range of endocrine problems, dermatological disorders , HIV associated opthamalogical diseases, malignancies, liver and kidney disease as well as the potential symptoms of these conditions are covered.

The one chapter, which was written by four authors, was titled Palliative and Spiritual Care of Persons with HIV and AIDS. This not only covered a discussion of the management of pain, other physical symptoms, behavioral symptoms including violent behavior and suicidality but it offered a review of models for spiritual care. The work of Breitbart and colleagues with cancer patients using meaning  centered interventions based on Victor Frankels ideas was introduced as was Kissane and colleagues description of a syndrome of  “demoralization” in the terminally ill which is distinct from depression. It consists of a triad of hopelessness, loss of meaning and existential distress expressed as a desire for death. A treatment approach for this state is outlined. This chapter concludes with a review of the role of psychiatrists and other clinicians at the time of death and afterwards. This includes a discussion of anticipatory, acute and complicated grief.

Although HIV disease and AIDS is no longer the mysterious disease which people are afraid to talk about and healthcare workers dread seeing patients with, nevertheless it is a very serious illness which cuts across all specialties and has great relevance for psychiatrists and other mental health professionals. It is estimated that more than one million people are living with HIV in the USA. Even now with retroviral treatment available, this disease is expected to infect 90 million people in Africa resulting in a minimum of 18 million orphans. Needless to say, this book should be translated into many languages and should be available internationally. This book gives us a full background about AIDS and allows psychiatrists and other mental health professionals to have this fund of knowledge at our fingertips. Also, if and when there is another deadly virus that appears on the scene, our profession will have a model and a valuable compendium of how to approach it, which is something we did not have thirty years ago.

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