Sunday, October 30, 2016

A Solo Psychiatrist's White Paper for America, Americans, and Immigrants

Mankind is driven “to have” and “to hold” food, shelter, and clothing, and persons, places, and things to survive. Thus, this could be called a “sovereign drive” that every man and every woman has. The word, “sovereign,” is a synthesis of reign (to have) and sover (to hold – to render safe from attack or injury). All sovereigns can resort to four techniques or weapons of sovereignty[1]: physical power, economic power, psychological power, and the use of or protection from propaganda. Those who are particularly resourceful to have and to hold more than others, earn the title, “Sovereign” or one of its synonyms. And when Sovereigns corral (“arch”) persons, places, and or things they earn another title, “Monarch” – one arch, or one of its synonyms.

As adult status emerged the colonists and immigrants acknowledged that Great Britain was denying them sovereignty, to have and to hold. Thomas Jefferson’s Declaration of Independence comprised the major premise – that “all men are created equal… with certain unalienable rights… life, liberty and the pursuit of happiness… that when [there is] a long train of abuses and usurpations…it is their duty to provide new guards for their future security.” Jefferson followed this with the minor premise – “… let facts…a long train of abuses and usurpations… be submitted to a candid world.” And lastly there was the conclusion: let there be a war for independence (that Americans are “popular” [people] sovereigns and have a right to have sovereignty).

Over 200 years have passed since the creation of the Constitution of the United States and the Bill of Rights, both documents serving to protect the sovereignty of Americans. We need to apply the same logic to our present situation that Jefferson applied in 1776.  I state this because these two documents are not being respected by those in power and by many Americans.  This is a trichotomy:  the wealthy who are primarily committed to their wealth;  those Americans and immigrants committed to the principles of America; and those who feel disillusioned.

Here is the minor premise – an abbreviated list of “abuses and usurpations”: immigrants are not being respected as vital to our survival; updating and repair of America’s infrastructure is not happening because of insufficient money; pluto-cracy (the power of the rich) suggests that they are obsessed with money and power, that plutocracy disempowers demo-cracy (people-power), and that there are many in the three branches of the federal government who are inclined to assist the rich; those appointed to and hired by bureaucracies often dismiss legitimate sovereign needs of Americans and immigrants; the middle class is diminishing in number; there are debtor’s prisons; a catch 22 – America wants Americans skilled in the sciences but ignores their incapacitating student debts; there are those in state government who usurp the right of pregnant girls and pregnant women to decide whether or not the fetus developing out of “dust” is healthy enough to harbor a soul, or that the soul does not deserve to be born into insufficient comfort, nurturing, money, or protection; there is an absence of understanding that children and adults with inhibited grief over the loss of persons, places, or things are more vulnerable to carrying out delinquent behavior; there are men and women without vocational and economic sovereignty; there are families with health problems and individuals and families without sufficient health or medical coverage; the American dream (to seek to have and to hold) is more and more difficult to achieve; that our cities are facing more and more of the marginalized, the homeless, the poor, the hungry, and the angry.

Local and national elections are the hallmark of democracy. American citizen - sovereignty and immigrant - sovereignty need to be acknowledged and carried out by the incumbent and by bona fide promises of candidates. America must have the elected carry out the techniques of sovereignty wisely, effectively, and for all Americans, including immigrants. The power of demo-cracy (people-power), sovereignty, needs to be revitalized by voting and by keeping plutocracy and bureaucracy from diluting the power of democracy.

[1] Marshall, James. Swords and Symbols. New York: Funk & Wagnalls, 1939, 1966, 1969: 20

Saturday, March 5, 2016

Metapersonality- the new frontier.

     Please find this peculiar treasure trove of metaphors, similes, and stories for those of you who are curious about personality. I call this “meta-personality.” Meta is a prefix that means “beyond.”  I will define for you the terms metaphor and simile in the following. And do not be afraid of metaphors, whose definition I never understood in grade or high school.

     A user-friendly definition of the word metaphor is available via etymology. Etymology is the study of the history of words, their origins, and how their form and meaning have changed over time. Metaphor is a synthesis (combination) of meta, meaning beyond, and phor, meaning structure. Just “make” someone into another structure! So, if you say or write to someone, “You are a fountain of knowledge,” you have turned them into a fountain! That is an example of a metaphor.

     Simile is easier. Just think of “similar.” If I say, “You are like or similar to a fountain of knowledge,” I have used a simile to describe you.

     This metapersonality adventure began in the early 1980s when a new patient of mine whose wife had separated from him asked me to get a copy of The I Ching or Book of Changes by Wilhelm and Baynes. I acquiesced to his request and read that Wilhelm translated this seeming 3000 year old Chinese text of Yin (female) and Yang (male) into German, and Cary Baynes translated the German into English.

     At my patient’s second session, knowing that I had obtained the text, he cited specific sentences and paragraphs for my take on them. He said he got these sentences and paragraphs by means of an oracular readout, which I later understood.  I read his cited sentences and then waited for him.

     He told me that the text supported his belief that he had the right to control his wife; that she had no choice but to return to him. I was momentarily at a loss for words. Was he serious? Did he want psychiatric support from me that his wife should act as his subject? As it turned out, that is exactly what he wanted.

     I told him that I did not share his interpretation. I suggested he look at the text from a psychiatric perspective, which advised that he treat his wife as an equal. Otherwise I believed his wife would not return to him. Did he not grasp why she had left him? He steadfastly disagreed with me. As you can imagine our professional relationship did not continue.

     A few weeks later I returned to my copy of the I Ching. The I Ching is comprised of three books in one: Book I – the text; Book II – the material; and Book III – the commentary. I chose Book I, which my patient had used, to see if I could find any usefulness in the I Ching. As I glanced at the titles for each of the 64 hexagram-chapters it occurred to me to look up hexagram 18, relating to my date of birth: 10-18-1933.

     The title of hexagram 18 read: “Work on what has been spoiled.” This seemed to accurately describe part of my personality. Interesting! Was that a coincidence or what? That impelled me to associate dates of birth of my major players with the I Ching.

     My father was born on 9-2-1903.  Hexagram 2 and its text is labeled, “Receptive.” My father always wanted us children and his other major players to be receptive to his lectures. One of my brothers was born on the 27th. The hexagram title is, “Corners of the mouth” (providing nourishment). This also fit. My brother always encouraged people to feel better. And ultimately intrigued, I discerned that my relatives’ dates of birth also correlated concretely and abstractly with the hexagrams. I then took this interesting project to my office. I began silently juxtaposing patients’ dates of birth to their personalities. And their dates also appeared to resonate. And then I thought, “Now what?”

     Assuming that the day of birth represented the personality we carry out during the bulk of our hours at an activity, what could or would the month and the year represent?

     My secretary at the time helped me out with one of the above. Ultimately a formula followed: the month of our birth is for the first minutes of each new situation; the day is for carrying out the bulk of hours at an ongoing activity; and the year is for confronting positive and negative challenges whenever they occurred.

     My birth month, October, was equivalent to the 10th Hexagram labelled “Treading.” It was right on as to metaphors and similes applicable to me at the start of new situations.  And 33, “Retreat,” for confronting challenges, left me confused for a time.  Did this suggest I would retreat from a challenge or would I re-treat a challenge? I discovered I did both.

     Not long after, a university professor, who learned of my interest in metapersonality, asked me to lecture his graduate students on basic elements of psychiatry and also some on meta-personality. I gladly accepted his request.

     I mentioned to the graduate students that at times patients were reluctant to take a psychotropic medication. To mitigate this fear I used the phrase, “If the shoe fits wear it.”  In other words if the medication seemed effective in decreasing the symptom continue to take it. I also spoke of when a patient might call my office to inform me of imminent suicidality. I would often verbalize, “I will not let you turn into a pumpkin, I will not let you commit suicide, so you must come to my office immediately."   

     I realized that the psychiatric challenge of a patient feeling suicidal lit up my “33”: to get my patient to “retreat” from being suicidal.  My “10” for the first minutes of this new situation would have them urgently “tread” to my office or to an emergency department. And my “18” would have me “Work on what has been spoiled.”

     During the break in my lecture a number of the students looked at my copy of the I Ching or at one or more of the New Age books I had with me. As we resumed, one of the students raised her hand to tell me something she found in one of the texts. And she wondered if I knew of her finding? She referred to my date of birth. She said, “Dr. Paltrow, do you realize that the phraseology you used before the break fit with the 18th chapter of Inner Child Cards?” “No,” I responded.  She then told the group that the 18th chapter was titled, “Cinderella,” which related to my expressions of “if the shoe fits” and the “pumpkin.”  I was fascinated with this student’s discovery that the role and or story of Cinderella did describe a facet(s) of my personality.

     If the book you are using does not have enough chapters for your day of birth (1-31) then consider using the individual numbers, e.g., chapters 3 and 1 for being born on the 31st.   The zero in any birthday (01 for January, or the 10th, 20th, and 30th) can be found using the zero chapter in the Inner Child Cards book.

     If the book you are using does not have the chapter for your year of birth, then consider using the I Ching.  Since there are 64 Hexagrams, subtract 64 from any higher year to get the applicable Hexagram.  For example, the year 1987 would just focus on the 87.  Subtract 64 (total number of hexagrams) from 87 and discover 23.  So, the 23rd, 8th, and 7th chapters could all apply to describe modi operandi for confronting challenge.

     Please keep in mind that the metapersonality I describe above compels us to think of metapersonality as being “logical.” Step 1 is called “Major premise”: one’s belief, finding, opinion, or perspective. Step 2 is called “Minor premise”: documentation or evidence to support the major premise. Step 3 of logic is the “Conclusion.”

     Yes, this post seems to compel logic when we discover literal and abstract correlations with our dates of birth. A trove of metaphors, similes, and stories that seem to describe our personalities could be seriously contemplated when our situations, settings, and comings and goings seem to be out of sync.   

     Here is a list of the nine new age books I use as reference for metapersonality. You might want to see if your library has any of these texts. Please start your adventure slowly, as I did, using whatever book you have as a reference, rather than as a novel or a book to read from cover to cover.  Enriched knowledge of each other’s personality helps each one of us to relate more peacefully to ourselves and to each other.

1. Wilhelm, Richard, and Cary F Baynes. The I Ching or Book of Changes. Princeton: Princeton University Press, 1971

2. Murphy, Joseph. Secrets of the I Ching. New York: Parker, 1973

3. Blum, Ralph H. The Book of Runes. New York: St. Martin’s press, 1993

4. Blum, Ralph H, and Susan Loughan. The Healing Runes. New York: St. Martin’s press, 1995

5. Sams, Jamie, and David Carson. Medicine Cards. New York: St. Martin’s press, 1999

6. Lerner, Isha, and Mark Lerner. Inner Child Cards. New Mexico: Bear & Company, 1992

7. Sams, Jamie. Sacred Past Cards. San Francisco: Harper, 1990

8. Sheppard, Susan. The Phoenix Cards. Vermont: Destiny Books, 1990

9. Carlsberg, Kim, and Darryl Anka. Contact Cards. New Mexico: Bear & Company, 1996

Saturday, November 7, 2015

The psychiatrist and the pregnant lady

         When we stop to smell the roses we can benefit with peace of mind.
     But more often we do not stop to smell the roses because of problems near and far. Problematic behavior (behavior means what one is or is not doing) can be examined via a Review of Areas assessment, culminating in a “behavior x-ray.” (1)(2)

     During my third year of residency in psychiatry I was assigned to the hospital outpatient liaison service. It was my role to respond to requests from the other specialties to carry out timely psychiatric consultation service. One afternoon a resident in obstetrics and gynecology (OB/GYN) contacted me to consult on a crisis.
     A forty-year-old female patient had come in two weeks before for more than the usual checkup for breast or cervical cancer. She had pigmentary changes around her nipples, enlargement of her abdomen, cessation of menses, and morning sickness and was absolutely certain she was pregnant.
     Even though the physical examination did not support the diagnosis of pregnancy the resident ordered the standard laboratory pregnancy test. During this follow-up visit in the clinic he told her she was not pregnant. This made her angry. She was adamant that she was pregnant. She had never been a mother and this was her one and only opportunity. Then, suddenly her anger turned into despair. If she was not pregnant she no longer wanted to live.
    The resident diagnosed her disorder that of pseudocyesis, a false pregnancy, one of the somatoform disorders. She had a delusion about her soma, the organic tissues of her body. Thus, the resident had a psychiatric crisis on his hands. I told this resident I would evaluate his patient in the OB/GYN clinic within the hour.
     Before meeting her I looked at the Biomedical Area in her chart and found no additional information of merit and I knew her major emotions. So I would gather information as to her behavior, what she had or had not been doing, in her social, vocational, recreational, and learning areas.
     I introduced myself. She was courteous, controlled her emotions, and indulged my questions knowing that no matter what I found or diagnosed she would not budge from her belief that she was pregnant.
     I was not surprised to discover that she had no social life with family or others, was not working, had no meaningful recreation or hobbies, and was not attending school or interested in current affairs. I wrote a brief note in the outpatient chart along with my hand-drawn ROA circle, her behavior x-ray, demonstrating deficiency in four areas. At my request she said she would remain in the OB/GYN clinic while I called the resident.

     I told him that the pseudocyesis was being fed by her metabolic energy, as this energy was totally confined to her emotional and biomedical areas. If we rejected her delusion she would probably take her life. Medication was out of the question because she would fear it would harm the fetus. The solution lay in integrating psychiatry and obstetrics.
     We needed to stall confronting her with the truth. The resident would tell his patient that he wanted a second pregnancy test to be certain. During the two-week interim for the test results his patient would attend an outpatient psychiatric group therapy that met twice a week. Hopefully, her metabolic energy would be diverted from fueling her delusion to fueling her revived social area.
     Two weeks later the OB/GYN resident called me. Before he could tell his patient that the lab test was again negative she blurted out that she hoped she was not pregnant. She was making friends in the group. She learned from them that it would be difficult for someone at her age of forty to raise a child on her own. A few lived near her so they were setting up plans to do things together. The group therapy gave her useful social behavior, which would undoubtedly expand to include recreational and possibly voluntary vocational behavior.
     Here is the final behavior x-ray:

Please consider:
     1. The ROA formula can be a simple, sophisticated, and rapid x-ray evaluation of behavior: what one is or is not doing.
     2. Metabolic energy that is confined to two areas can be problematic.
     3. Each one of us is a tree in the forest of mankind. To be able to smell the roses might oblige us to use a formula such as the ROA to examine and heal problematic behavior of ourselves and our forest.
     4. The integration of psychiatry and medicine has great potential to maneuver metabolic energy. It led to removal of a patient’s delusion that she was pregnant.

(1) Paltrow KG, Brophy JJ. Review of areas: A Key to diagnosis. McGraw-Hill, Inc. Postgraduate Medicine 42: A 137-A 141, December 1967©

(2) Paltrow KG. Review of areas: Updated method of patient evaluation. McGraw-Hill, Inc. Postgraduate Medicine Vol 67/NO 1: 211-215 Jan 1980©.

Sunday, February 8, 2015

Paltrow's Pie

     It was in early July 1964 when I had just begun a three-year psychiatry residency at Oregon Health and Science University (OHSU), previously the University of Oregon Medical School in Portland, Oregon. It was the first time I was assigned to a hospital ward designated solely for psychiatric patients and within the first week of the residency I became painfully aware that I did not know what I was doing.  During the second week of the residency the chief of psychiatry became professionally aware that I did not know what I was doing.  In the presence of the three other first year residents and the third-year resident, during my description of my patients, he said, “Ken, you do not know what you are doing!” I replied, “I know that. I have no idea what I am doing. I was hoping I would learn my way as to how to be a psychiatrist.” He turned to the third-year psychiatrist and said, “Take Ken under your wing until he knows what to do.”

    I continued following the outline for psychiatric evaluations. The myriad information we were to acquire from patients did not seem to funnel into any formula or template.  Further, it seemed that the psychiatric evaluation gave the patient’s medical and surgical history less than equal attention.  I hoped I was wrong in that perception. I became apprehensive I might have to forfeit my accumulated medical knowledge and experiences in order to become a psychiatrist.  I had four years of medical school, one year of rotating internship, one year of surgical residency, one year of neurology residency, and three years stationed in France carrying out general medicine and neurology for the Medical Corps of the United States Army. I began feeling anxious, depressed, and sometimes I did not sleep well. I felt chagrined about not completing the two former residencies and now I was feeling uneasy with this residency in psychiatry.  I decided to stick it out, however, hoping for a solution.  The third-year resident did review each one of my psychiatric evaluations and made some suggestions, but I did not mention my thoughts and fears to him.

    One of my patients was a child who was blind, whose residence for each grade school year was the Oregon School for the Blind in Salem, Oregon. As a result of this connection I was invited to join the faculty at one of their conferences being held in Lincoln City at the Pacific coast. The faculty felt challenged to get a handle on all the different activities their students did on and off campus. It seemed similar to my attempt to get a handle on the myriad information per psychiatric patient.
    When I wrote up the medical and surgical history for each patient I used the formula familiar to all physicians, the Review of Systems, created by a German physician, Rudolph Virchow.  Here are a few of these familiar systems in our body: cardiovascular (heart and blood vessels), gastrointestinal (digestive), musculoskeletal (muscles and skeleton) , skin, and neurological (brain and nerves).  Each system is examined as to: normal, deficient, excessive, maladaptive, or obsolete behavior. Behavior is what someone or something is doing. Thanks to Virchow two amazing things occurred to me and it was the answer to my prayer. I became very excited. I felt that I finally had a formula for psychiatry that adequately included medical and surgical history. I stopped experiencing anxiety, depression, and insomnia.

    If the human body can be divided into systems and examined for behavior why not divide human activity into areas and examine these areas for behavior?


    I came up with six areas and called it the Review of Areas© . I drew a circle. Using this Review of Areas©  formula or template I could sort the patient’s myriad information into six areas of behavior: biologic, social, vocational, avocational, learning, and emotional.  I could give each area the attention it deserved.

    Not long after, I was on a three-month rotation at one of the state hospitals in Oregon.  Each one of my 15 or so patients gave me permission to share his or her Review of Areas circle on a 4“x 5” page from a memo pad with the other patients. The nursing staff let me tape their pages on a seldom used window at the nurses’ station. The patients gathered around this window to compare their  circles.  They were startled that the majority of their pie diagrams were similar: “behavior” in only two of the six areas: biologic and emotional.

    Upon returning to the medical school I continued the same bulletin board idea. The nurses began calling the Review of Areas©  diagram “Paltrow’s Pie.” And then one of the residents asked me if I planned to get it published. I told him I had not considered it, I had not written any articles for medical journals, and that I did not have the skill for writing. He told me he thought the Review of Areas©  was a valuable formula, that he had written articles that had been published, and he would like to assist me in writing this article.  I accepted his assistance.

    For the subject of the article I chose a patient who, many years before, was injured during a fall into an open manhole. He then underwent a number of operations. For four years he received physiotherapy from an orthopedic surgeon. Then for 2 ½ years he was treated by a psychiatrist for anxiety, depression, delusions, and suicidal thoughts. When he became my patient on the psychiatric ward at the medical school hospital I carried out my Review of Areas©  formula for information.  After I prescribed psychiatric medication I showed him the diagram. Like the others before, he was “behaving” in just two areas: biologic and emotional. I sought help for his deficient social area: he began taking walks with his wife, met with neighbors, spent more time with his brother, and resumed attendance at union  meetings. For his deficient vocational area his union representative placed his name on a job availability list taking into consideration his physical limitations. For his deficient avocational area he resumed his hobby of wood carving. He avoided his deficient learning area choosing not to study or learn any new subjects. The outcome was that he did return to his trade as a machinist. He had ceased being suicidal. He had stopped experiencing delusions. His pain gradually decreased as did his anxiety and depression. His self-esteem increased. Medication was gradually reduced and essentially discontinued.                            

    We submitted the article to a medical journal and it was accepted for publication in 1967. (1) I received many postcard requests for reprints, many from around the world.

    Consider the law of conservation of energy. Energy can be converted, transferred, and transformed. I was intrigued that this Review of Areas©  formula offered a picture of a person's transference of energy. Deficient use of energy in one or more areas simply transfers or shifts energy to other areas. For example, deficient expenditure of energy in one's social, vocational, recreational, and learning areas results in excess expenditure of energy in one's emotional and biologic areas. Common sense and reason support efforts to revive use of energy in deficient areas. Creating (or re-creating) behavior to be as normal as possible in as many areas as possible could reduce anxiety, depression, delusions, pain, and suicidal ideation, and in return increase one’s self-esteem and productivity.

    In 1980 I took advantage of my continuing expertise in the Review of Areas©  to update it with two name changes: “biomedical” for biologic and “recreational” for avocational.  (2) And again, I received requests for reprints from around the world.

    My update included details for each area that could be looked at for normal, deficient, excessive, abnormal, or obsolete behavior including:
  • Biomedical area: review of systems, current symptoms to include hallucinations and delusions; history of illnesses, accidents, operations and other treatment, and family medical/surgical history, etc.
  • Social area: family, relatives, friends, marriage/divorce, social organizations, anniversaries, economic status, legal history, government, cultural background, geography, pets, and animals, etc.
  • Vocational area: current vocation and history of vocation to include military service, and the labor involved carrying out activities of daily living, etc.
  • Recreational area: hobbies, interests, pastimes, activities of play, spectator activities; and two new interpretations--to be creative and to re-create.
  • Learning area: history of formal education, informal education, and self learning.
  • Emotional area: feelings and emotions that pertain to the present, the past, and the future? And how are these feelings handled? An addition for this area could be a description of personality.

Yes, I stayed with this residency. The Review of Areas formula made all the difference and I continue to use it in my practice to this day.

(1) Paltrow KG, Brophy JJ. “Review of areas: A Key to diagnosis.” Postgraduate Medicine 42: A 137-A 141, December 1967© McGraw-Hill, Inc.
(2) Paltrow KG. “Review of areas: Updated method of patient evaluation.” Postgraduate Medicine Vol 67/NO 1/Jan 1980: 211-215 ©McGraw-Hill, Inc.