Nasty Little Holes

those horrible lotus seeds

those horrible lotus seeds

Three caveats before I dive into this very strange topic:

First, I own a pet Lesser Sulfur Crested Cockatoo which was rescued from a meth lab outside Gastonia NC (where she was being employed as the proverbial ‘canary in a coalmine.’) As her subspecies is critically endangered in the wild, it’s almost certain that she was hatched here in the U.S. Because of that, Koko has never seen any of the predators that would normally populate her home in East Timor. But she totally ‘loses it’ when one of my family approaches her cage wearing a leopard print blouse. Evolutionarily, Koko knows that such a pattern is bad news, and she reacts quite viscerally to it.

Second, looking back over my medical training and subsequent career, I’ve encountered some fairly disgusting things. Self mutilations? Check. Head traumas? Been there. Major abdominal surgeries? Yup. Autopsies? Yawn. But far and away, the most revolting cases came from… dermatology. To really churn one’s stomach, nothing compares with skin diseases.

Third, I still, to this day, remember a vivid and upsetting dream I experienced as an adolescent. It involved seeing a classmate, nameless, faceless, with her arms bandaged. In the dream, she removed the wrap, and underneath, both of her forearms were covered with deep holes, and inside of each one was an insect. I don’t have any idea what triggered this thought in my subconscious, but the dream occurred years before I had ever heard of the subject matter of today’s post, and it has obviously stayed with me all of these years.

Keeping those observations in mind, I now present you with Trypophobia, the fear of small irregularly shaped cavities (or blisters, fissures, and bumps, from the Greek root trypo, for hole). This may sound like a joke, but to those who are purported to suffer from it, the condition is anything but funny. And from a quick Google search online, there seem to be a lot of folks out there who are afflicted – or at least who talk about it. Which is even more odd given that in my 27+ years of clinical work, I’ve never encountered a single patient who endorsed these symptoms, nor was I ever instructed that the condition may even exist!

Specifically, trypophobes say that certain images are ‘triggers’ that reliably produce gastrointestinal symptoms (e.g., diarrhea, nausea, vomiting) as well as more classically psychogenic ones (e.g., sheer panic, dread, diaphoresis, tachycardia, vertigo).

If you look online, you will see frequent mention of triggers both innocuous and nightmarish:

skin conditions, such as severe athletes foot, chicken pox, measles, and deep cystic acne;

maggots doing their thing;

plants with cystic structures or reproductive pods, such as lotus seed heads, cantaloupes, or pomegranates;

porous coral formations;

soap foam;

the honeycombs of bees;

pancakes with little bubbles in them;

circular shower drains;

popcorn (and bumpy popcorn-finishes on ceilings);

sponges;

gross

gross

weathered sandstone;

gasp!

and pregnant Surinam Toads, the dorsal aspects of which are pockmarked by gestating young under the skin – and then those little buggers squeeze out of holes in mamma’s back when developed.

There are researchers who claim that some people’s repulsion to certain stimuli is an unconscious evolutionary association vis a vis dangerous animals/ organisms or infectious conditions that have ‘the look,’ and from which we’re wired to stay far far away, for our own safety.

Others, however, state that so-called trypophobia is nothing more than conditioned yet over-generalized disgust to possible contaminants and unpleasant images – think rotting corpses – fanned by pop psychology, photoshopping, armchair diagnosis, and the internet.

[sidebar: and we all know that if something is on the internet, it must be true]

Anyone who has read my blog for a length of time will be aware of my jaundiced view of ever-increasing disease categories in the Diagnostic and Statistical Manual. That noted, there is a lag-time between identifying a condition and having it gain wide acceptance within the profession (e.g., Seasonal Affective Disorder, about which Scandinavians have known for centuries, but which didn’t make ‘the cut’ in early editions of the DSM).

Will trypophobia also make ‘the cut,’ or instead join the ranks of far more suspect ailments like sex addiction and multiple personalities? I’m not sure yet. Either way, don’t now go to YouTube and look for videos of parasitic bot fly infestations. You have been warned.

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[Copyright 2013 @ The Alienist’s Compendium]

Nocebos

I have written previously about the placebo effect, especially as it pertains to psychotropics in general, and soporifics (sleeping pills) in particular.

It’s well known that if a patient believes a drug will work, it is far more likely to produce subjective relief of symptoms. This is even more noticeable if a patient believes a drug will work AND is expensive (i.e., studies have shown that telling a patient that a medication/ placebo is generic, as opposed to the “costly name brand,” cuts down on placebo-efficacy).

Placebos are a testament to the power of the human brain to overcome some medical issues. There is, however, a downside. If we can convince ourselves that a non-treatment is making us better, can we also similarly convince ourselves that a non-malady is making us sick?

The answer is ‘yes,’ and it’s called the nocebo effect.

The New York Times wrote in August 2012 of a patient in an antidepressant drug trial who was, unbeknownst to her, in the placebo arm of the study. She overdosed on almost fifty of the sugar pills in a suicide attempt. Even though the tablets were chemically harmless, the participant’s blood pressure is said to have dropped precipitously following her ingestion (she lived).

It would seem that the nocebo effect is real and, potentially, problematic. To make matters worse, nocebos – even though they are solely comprised of thoughts resident in our own minds – can be contagious.

An example of a contagious nocebo can be found with ‘wind turbine syndrome.’ That’s not actually a medically-recognized condition. Many in the public, however, believe that the large electricity-producing windmills emit a barely audible buzzing noise, one which can result in nausea, dizziness, fatigue, tinnitus (ringing in the ears), and headaches.

Scientists have postulated, however, that when multiple individuals near wind turbines complain of these symptoms, it’s a result of a ‘communicated condition,’ one that, like a mass hysteria, spreads from mind to mind. People can literally worry themselves sick.

Simon Chapman, PhD, a professor of public health in Australia, is quoted in The Guardian as stating, “if wind farms were intrinsically unhealthy or dangerous in some way, we would expect to see complaints applying to all of them, but in fact there is a large number where there have been no complaints at all.”

Chapman cited a study out of New Zealand that exposed 60 healthy volunteers to both real and fake low-frequency noises, the former similar to what is produced by wind turbines and is sometimes known as infrasound. Half of the volunteers were shown television documentaries about the purported health problems associated with wind turbines, while the other half were not. Then both groups were played random noises: some infrasound, some not, and some a mixture. And those who had seen the videos about the allegedly adverse effects reported higher levels of subjective symptoms regardless of the type of noise to which they were exposed.

The wind turbines may be harmless, but breathless media coverage of them isn’t. In the words of one perplexed scientist, news stories about wind turbine syndrome aren’t reporting on the disease… they’re actually creating and spreading it!

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[Copyright 2013 @ The Alienist’s Compendium]

Hamilton Beach meets Adam and Eve

Are you female?

Are you having trouble sleeping?

Are you experiencing fluid retention?

Are you irritable?

Do you have a tendency to “cause trouble”?

If so, based on medical texts from the late 19thc, you are obviously a hysteric. As many as 75% of middle class women in America were then thought to suffer this ailment. And at the time, the standard of care – for those women who couldn’t afford to travel to Europe and lie on Freud’s couch – was a “pelvic massage” resulting in therapeutic “hysterical paroxysms.”

In other words, the patient needed a medical sex surrogate to bring her to climax (weekly was the suggested frequency) and all would be restored to normalcy.

Today, this strangely sexless office sex would almost certainly result in a lawsuit and loss of licensure. Not so in 1900.

Apparently most doctors at the time found the manipulation to be tedious, as literature of the day reported with seeming straight face that it often took hours to accomplish. The good doctor needed something to assist.

Enter the vibrator.

The first vibrator, called a “massage and vibratory apparatus,” was invented and patented in the U.S. by George Taylor MD in 1869. It was steam powered, large, heavy, and sold only to physicians and spas. It was hardly discreet.

One must wonder: did females see the clinician unwrapping said apparatus and feel even fleeting anticipation, or just the kind of dull disinterest one would experience while watching a mechanic change the car’s oil?

The first (smaller) battery powered unit followed from the fertile mind of British physician Joseph Granville a mere eleven years later. Manufactured by the Weiss Company, it was lighter, easier to move, and less expensive than the Taylor machines.

Then homes started to be wired for electricity. By 1900, there were more than a dozen companies in the U.S. and U.K. that were churning out mothers’ little (plug-in) helpers. The Age of Electricity saw the advent of the electric sewing machine, the electric fan, the electric tea kettle, the electric toaster… and these contraptions (which, I might add, predate the electric vacuum cleaner). To our modern eyes, such devices hardly seem alluring. The giant noisy motors. The thick cloth that covered the cords to prevent sparks from flying. The need to add oil occasionally – that last feature yielding the ambience of a bedroom chainsaw.

Marketing was then expanded beyond medical journals. Ads began to appear in Modern Woman and Woman’s Home Companion. These ads remain legendary, promoting such claims as “relieves all suffering,” “wonderfully refreshing,” and “curative of many diseases.” Gushed one, “it can be used by yourself in the privacy of dressing room or boudoir, and will furnish every woman with the essence of perpetual youth!”

And they were economical too. With doctors charging $2 per, er, treatment at the turn of the century, the $5.95 cost of hand-held plug-ins meant that a machine paid for itself after a mere three self-help sessions.

Throughout the 1910s and ’20s, print ads flourished, providing hysterics around the country with relief, courtesy of USPS mail order. Hamilton Beach made such equipment. So did Sears Roebuck, their 1918 catalog vaguely mentioning that the devices were “very useful and satisfactory for home service,” hoping you got the idea and no further explanation was necessary.

Vibro-Life, Eureka Vibrator Co, 1908

Vibro-Life, Eureka Vibrator Co, 1908

There also existed, briefly, pneumatic and hand-cranked models, Macaura’s Pulsocon from the 1890s and the Vibro-Life from 1908 being examples of the latter. Given the relatively recent cultural vogue of total depilation, one cannot help but ponder the cringe-worthy outcomes of applying to one’s self, pre-Brazilian waxes, a metal instrument that twisted not unlike a baker’s mixer.

Even though it was a poorly kept secret – wink wink – once vibrators began to appear in naughty pictures, they were driven almost instantly from the pages of ‘respectable’ publications. They reappeared only during the Sexual Revolution of the ‘60s, and then purely and unabashedly as erotica, where they have remained to this day, their stiff-collared Victorian roots notwithstanding.

Interested in further reading? Google ‘antique vibrator museum’ and be amazed by the collection on display in San Francisco. Better, plan a visit there the next time you’re in town

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[Copyright 2013 @ The Alienist’s Compendium]

The Alleged Lunatics’ Friends Society

[Today’s post is sponsored by our very own Audrey E. Alford – welcome back to state government!]

Georgina Weldon (1837 – 1914) was an accomplished British soprano of the 19th century. Classically trained in Florence, she ran afoul of her rich father by going against his wishes regarding marriage. Unfortunately, her new husband was no more supportive of his bride than was her father, and the former then forbade Georgina to appear professionally on stage. Disinherited from wealth and prohibited from earning by her own skills, Georgina was relegated to the occasional performance, gratis, for local charities.

Georgina Weldon

Georgina Weldon

Before long, Georgina and her husband divorced so that he could cohabit with his mistress. Harry Weldon then reneged on his alimony agreement, and Georgina promptly sued – a rarity for a woman in 19th century Britain. Harry immediately tried to have Georgina declared insane and committed to an asylum (freeing him from alimony). On flimsy testimony the court agreed with Harry, and the order was signed. Georgina caught wind of this and hid until the warrant for her commitment had expired. She then immediately filed suit against Harry and his confederates for attempted assault on her person.

Thus started Georgina’s second career as a repeat and oft-annoying litigant. Sometimes she was successful, but many times she was not – once even spending time in jail when convicted in countersuit of libel. There was a time in the 1870s when she had 17 concurrent lawsuits pending against a series of defendants for a variety of slights, real and perceived. However, by then unshackled of her husband, she started singing professionally to finance her legal ‘habit.’ She also found time, in 1882, to publish The Outpourings of an Alleged Lunatic, or How I Escaped the Mad Doctors.

While not an official member, Georgina Weldon’s efforts coincided chronologically and conceptually with those of the interestingly-named Alleged Lunatics’ Friends Society. The ALFS had been founded in 1845 in London to address what its members saw as abuses in then-enforced British commitment laws. Miscarriages of justice were rampant, especially since doctors at the time relied on subjective hearsay from biased sources when testifying at commitment hearings. They often equated benign eccentricities and perceived immoralities as insanity per se – keep in mind that private for-profit madhouses then still existed, and there were profits to be made as well.

The commitment laws were used to muffle those who were odd at best and socially irritating at worst. “Uppity” women were often targets of the commitment laws, as in Georgina’s case; those foolishly contesting inheritances against powerful and well-placed relatives were often another targeted group.

In a particularly egregious case litigated (successfully) by the ALFS, one Jane Bright, a member of the wealthy Brights of Skeffington Hall in Leicestershire, had been seduced by her physician, who took most of her money and left her pregnant. Soon after the birth of her bastard child, Jane’s brothers had her committed to Northampton Asylum to get her out of the way. On her eventual release, she enlisted Gilbert Bolden, the ALFS’ solicitor, to help her recover the remains of her fortune from her family.

Sadly, Georgina Weldon’s operatic career flagged, and she became known more as an eccentric than as a crusader for women’s and patients’ rights. And the ALFS eventually went defunct, having failed to garner much public support. However, to the Society’s credit and Georgina’s legacy, both were successful in initially drawing attention to widespread abuses in the mental health system of the 19th century United Kingdom. They were amongst the first and most vocal advocates dedicated to greater protection against wrongful confinement in the Western world.

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[Copyright 2013 @ The Alienist’s Compendium]

Gaydar

Canadians – by and large a kind and considerate bunch – were once as blindly homophobic as any of the McCarthyites down South. In the late 1950s, the Royal Canadian Mounted Police (RCMP) initiated a ‘scientific’ protocol to weed out homosexuals from the military, law enforcement, and civil service, deeming them a security risk. Section A-3 of the RCMP did nothing else but find and dismiss suspected homosexuals from all branches of the government.

At first this ‘gaydar’ involved following people to nightclubs – costly and deemed inefficient. Then came the “Fruit Machine,” invented by Professor Robt Wake of the Dept of Psychology of Carleton University, an otherwise prominent man of science. His device measured pupillary response, along with respirations, blood pressure, and pulse rate when a subject seated in a dentist’s chair was shown nude pictures of both men and women. Vital signs were also measured when the subject heard the words “gay,” “queer,” “drag,” and other slurs piped through a set of headphones. If the subject’s autonomic responses indicated arousal (physiologic, though not necessarily sexual), they were flagged and likely dismissed.

But the science itself was grossly flawed – depending on the light exposure in each photo, for example, the pupils could react due to nothing more than the brightness.

Never fear! Once funding for the Fruit Machine was caboshed, the RCMP fell back on good old fashioned penile plethysmography (aka ‘the postage stamp test,’ by which erections are measured while subjects are shown erotica). Not as scientifically flawed as the Fruit Machine per se, plethysmography is nonetheless still too unreliable on which to base such summary dismissals.

Both programs were terminated, but not before more than 400 otherwise innocent people lost their security clearances and jobs (and employability).

American Fruit Machine

American Fruit Machine

Interestingly, no Canadian versions of the Fruit Machine are known to exist, though an American model is on display at Canada’s War Museum.

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[Copyright 2013 @ The Alienist’s Compendium]

Hybristophilia

Hybristophilia is a mental condition – termed a paraphilia – in which romantic and sexual arousal is contingent on being with a partner known to have committed serious transgressions against societal norms, the most extreme cases involving crimes such as rape, robbery, and murder. Some (usually women) who fall prey to hybristophilia believe they can change the delinquent. Some find an adrenalin rush in the forbidden and dangerous. Some crave the limelight. Some desire the ultimate alpha male. Some have difficulty forming relationships with love interests who are staid, conservative, and actually available. This is a phenom that spans the gamut, from the oft-noted tendency of the prettiest girls in the high school class to gravitate to the ‘bad boys,’ to the fact that many incarcerated criminals receive bags of fan mail, love letters, and marriage proposals – Ted Bundy, Jeffrey Dahmer, Richard Ramirez, and Charles Manson all come to mind.

Usually those who exhibit hybristophilia are not famous in their own right, but there are exceptions. Belle Starr, the bandit queen of the old West, was a middle class wife in a boring but respectable marriage who then romantically gravitated to at least three notorious outlaws before attaining criminal fame herself. Patti Hearst is another possible example.

In popular literature, this is sometimes referenced as “Bonnie and Clyde Syndrome.” And with good reason.

Bonnie Parker

Bonnie Parker

During their lifetimes, that outlaw couple’s depiction may have been at considerable odds with the hardscrabble reality, but most titillating was the whiff of illicit sex; they were wild and young and untamed and undoubtedly hormonal. But while Bonnie Parker was present at the commission of no fewer than one hundred felonies during her two years as Clyde Barrow’s lover, she was not the lethal machine-gun wielding killer portrayed by period newspapers, newsreels, and pulp detective magazines. An (almost certainly playful gag) photograph of Bonnie found by the police at one uncovered hideout showed her posing with guns in front of their getaway car. However, gang member W.D. Jones later testified that he was uncertain if he had ever seen Bonnie fire at any policeman. It seems that Clyde did all of the shooting, and many now believe that Bonnie was along for the exciting ride.

It was an exciting ride that ended on 23 May 1934 in Bienville Parish, Louisiana, when the pair was ambushed and killed by a posse sent to stop them.

Her comparative non-violence and romantic obsession notwithstanding, this is not to say that Bonnie didn’t pack heat; when her body was taken to nearby Conger Furniture Store and Funeral Home in Arcadia for autopsy and embalming following her death, a .38 Colt M1902 pistol was discovered hidden in the folds of her skirt – it sold recently at auction for almost $100,000.

http://caseantiques.com/item/lot-404-38-colt-model-1902-pistol-bonnie-clyde-2/

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[Copyright 2013 @ The Alienist’s Compendium]

HIPAA

The Kennedy-Kassebaum Act, otherwise known as the Health Insurance Portability and Accountability Act (HIPAA), was passed by Congress and signed in 1996 by then-President Bill Clinton. It is a law with many good features; for example, it protects health insurance coverage for workers and their families when a breadwinner changes jobs or loses a job.

But it is also a many-headed beast, and has been both lauded and vilified almost since the day it became law.

One ongoing conundrum is its treatment of patient privacy. HIPAA establishes national standards for “covered entities” (think: providers and their agents) regarding the security of “protected health information” (think: medical records). These standards cover not only collection and storage, but also all subsequent transactions involving protected information. With very few statutory exceptions – court-ordered searches for missing persons or criminal investigations of child abuse are two – this information cannot be released by a covered entity without the written consent of the subject.

On the surface, that sounds good in an age in which privacy is eroding daily, Big Brother is watching, and identity theft is an ever-increasing problem.

But the pendulum always seems to swing too far.

*Recently, I accompanied a family member – who shares the same surname – to a doctor’s office, with the plan that I would go shopping and return later for pick-up. When I asked at the desk – the same desk at which I had stood less than 90 minutes previously – I was told that not only could the staff not tell me when my relative would be done, but they couldn’t even confirm that my relative was, in fact, in the office at all, “because it would be a HIPAA violation.”

*On one maximum security (locked) psychiatric unit that I once supervised, all of the patient charts were kept in a rolling cart at the nurses’ station for easy access of clinical staff. The cart was often turned toward those seated at the station’s desk, meaning that, if one had really good eyesight or even cared, the names on the charts could be seen by a person standing at the station’s window. Keep in mind that this was a locked unit, and the only people present were staff, committed patients, and the occasional escorted visitor. Still, we were told that we could be cited for a HIPAA violation if the cart remained facing the window where visitors could potentially see the names.

I mention these scenarios because it’s easy to lament how ridiculous rules and regulations have become… until one remembers what it was like in the past.

My maternal grandparents were married at the turn of the 20th century and then lived in the tiny hamlet of Appley, in far western Somersetshire, England. I’m not even sure how large is Appley today, mainly because I can’t find it in any recent census roster. Having visited once, I’m certain, though, that there are no more than a few dozen full time residents, if that many. In 1890 it must have been even smaller.

In good English form, though, there is a pub in town called the Globe Inn, which is still in business after more than a century. Appley is so small that the Globe is the only landmark that shows when the village is searched on Google Maps.

http://globeinnappley.co.uk/

Apparently in the late 1890s, there was also a physician who called Appley home. I don’t know his name or anything about his practice, except that my grandmother talked about going to see him when she was a young woman.

If any of the locals had a perceived medical problem, they would have to walk to the doctor’s house and wait outside, rain or shine, until 9:00 a.m. At that time, a woman would emerge from the house and begin to interview the crowd that had gathered. This was not done in private. It was done on the sidewalk. The woman would listen, and then either tell the potential patient, “go home,” or else, “come inside.” Those admitted to the house would wait in the parlor until the doctor was able to see them.

So who was the woman screener? A nurse? A midwife? Someone in medical training? No, it was the doctor’s housekeeper, a resident of town with no formal education or experience who was making triage decisions as to who needed help and who didn’t!

I’m sure that much gossip started from those sidewalk screenings, and then traveled like wildfire in the confines of small-town Somerset. And that makes me think that HIPAA, properly implemented, ain’t such a bad thing after all.

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

[Copyright 2013 @ The Alienist’s Compendium]

Just Anger

It is not uncommon for some to see a psychiatrist to attempt to gain a mental diagnosis and a subsequent disability check. By no means, though, is psychiatry the only medical discipline that encounters those who fabricate; it’s found everywhere, and unfortunately such ‘gaming’ of the system happens all too frequently. Not only is it indisputably dishonest, but when successful, it robs from our limited resources those monies that would otherwise be spent caring for individuals with legitimately disabling conditions.

The reader may take small solace, then, in the knowledge that such trickery is by no means new, nor restricted solely to our 21st century.

Paré Frontispiece

Paré Frontispiece

The 1634 edition of the works of French surgeon Ambrose Paré include several stories of frauds who pretended to be suffering from horrible ailments for the purpose of begging in the street from sympathetic pedestrians. His introduction included the warning that such beggars were not only not desperate, but were capable of other criminal actions, and that the honest charitable reader should take heed.

In his words, “some there be who are not content to have mangled and ulcerated their limbs with caustic herbs… or to have made their bodies more swollen, or else lean, with medicated drinks, or to have deformed themselves in some other way, but from good and honest citizens who have charitably relieved them, they have then stolen children! [All the while] pitifully complaining that they came by this [physical] mischance by thunder or lightning or some other strange accident.”

Paré tells the first clinical case in his text: “Not very long ago, a woman offered herself [for charity because] her womb was fallen down by a dangerous and difficult birth, wherefore she was unable to work for her living. Then [those running the charity] commanded that she be tried and examined, according to the custom, by the chirurgians (surgeons) therefore appointed. Who, seeing how the whole business was carried, made report that she was a counterfeit, for she had thrust an ox’s bladder, besmeared with beastly blood, into the neck of her womb…. For this she was put into prison, and being first whipped, was after banished.”

And then he relates a second case: “There came presently to us a well flesh’d woman, begging alms, and taking up her coat and her smock, she showed a great gut hanging down some half a foot, which seemed as if it had hanged out of her fundamnet [anus], [from which] there dropped filth like pus, which had stained her legs and smock, most beastly and filthy to look upon. [My colleague] asked her how long she had been troubled with this disease; she answered that it was four years since she first had it. Hence he easily gathered that she played the counterfeit, for it was not likely that such abundance of purulent matter came forth of the body of so well flesh’d and colored a woman; for she would rather have been very lean and in a consumption. Wherefore provoked with just anger, by reason of the wickedness of the deceit, he ran upon her and threw her down upon the ground, and trod her under his feet, and hit her with blows upon the belly, so that he made the gut which hung [down], to come away, and by threatening her with more grievous punishment, made her confess that it was not her gut, but that of an ox, which being filled with blood and milk, and tied at both ends, she put into her fundament, and let the filth flow forth at very little holes.”

What is perhaps of most interest is not the fakery nor the repeated use of body parts from oxen. Rather, the doctor’s assault is reported without shame or regret; it is seen as stemming from just and righteous anger, fully expected of a medical professional when uncovering a fraud who was preying on the good.

Imagine doing that today!

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[Copyright 2013 @ The Alienist’s Compendium]

Homicide in the Good Ol’ Days

Because of the 24/ 7/ 365 news environment in which we live, it is easy to assume that the perceived deterioration of society in general, and the unfettered growth of psychopathy in particular, are modern phenoms. While there is no way to refute this unequivocally, I suspect that psychopaths have existed since time immemorial. We just do not realize the chronology and full extent of the rapacity because of the lack of extant records, questionable diagnostic skills of the day, and criminal investigations that were then primitive at best.

A personal case-in-point: I have visited Appley, the small town in Somerset, England, where my maternal grandparents and their parents lived in the 19th century. It is barely more than a wide spot in the road. It looks as though nothing dangerous could ever be found in those bucolic fields and forests. I doubt any resident ever locked the front door. But in 1901, my grandmother’s younger sister was accosted by an unknown assailant wielding a blunt object while on her way home one afternoon. In pre-antibiotic days, she developed peritonitis from the assault, and unfortunately prior to lapsing into coma was unable to identify the person responsible. She died shortly thereafter at the age of fourteen. Victoria was on the throne and Britannia ruled the waves. But no one was ever caught, and the hangman at Tyburn denied his due.

While not common, monsters did lurk, then as now. Anyone who has read the best-selling Devil in the White City knows this. The risk of untimely death, whether from disease and filth, incompetent medical care, accident, or the predations of the evil, was very real indeed. In the case of the lattermost, forensic science was not often able to catch the guilty.

The second case-in-point, and the topic of this post, comes from across the Pond, and is arguably worse than my great aunt’s demise if only because of the numbers involved. A family of German immigrants, the Benders, had moved west from Ohio to claim vacant lands in Labette County, Kansas, just after the American Civil War. The 160-acre property in question had been vacated by Osage Indians who were forcibly transported to their new ‘home’ on the reservation in Oklahoma. Patriarch John Bender, his wife ‘Ma’ (history does not record her given name), his son John Jr., and his daughter Kate established a small inn and general store near Cherryvale, amongst a community of likeminded spiritualists and homesteaders.

The Bender business and residence were situated directly adjacent to the Great Osage Trail, the most well-established route to points further west. The Benders became renowned, though not for their retail and hospitality endeavors. Widely distributed flyers and broadsides touted daughter Kate’s psychic skills and supernatural healing abilities, and her séances and lectures on free-love became big attractions for those passing through the area.

Unfortunately for some who stopped in Kansas on the way to California, the Benders developed renown for other reasons, especially as their inn became the final and eternal stop for many a weary traveler. Beginning in 1871, there were a series of disappearances of those heading west who seemingly never made it past Cherryvale. It took a while, but by 1873 suspicions began to circulate about the Benders themselves. A town meeting was held during which it was decided to confront John and his family… but when the townspeople arrived at the homestead, they found it deserted.

Upon entering the abandoned inn, the search party detected a horrible smell. A trap door on the first floor under a bed revealed a subterranean cavity dug into the ground, the soil of which was soaked with what appeared to be congealed blood. The men of the town then began to dig under the house, but no remains were there found. However, probing the garden and orchard next to the house was more productive, and soon produced the decomposed body of William York, a doctor who had recently been heading through town searching for family members who had themselves earlier disappeared.

searching the Bender property (courtesy of the Kansas Historical Society)

searching the Bender property (courtesy of the Kansas Historical Society)

York’s remains were not the last. Many more bodies were located in adjacent fields, a creek bed, and in the well. Eventually the number grew to over twenty. Further, there were limbs unearthed that did not match any of the intact corpses. All of the victims did have one thing in common, though – their heads had been crushed by a heavy club, and their throats were then slashed for good measure. Newspapers of the day additionally reported that the female dead had been “indecently mutilated.”

The (mostly) unclaimed remains were buried in a mass grave nearby, still known as “Bender Mound.” A sledgehammer and some cobbler’s tools found near the killing fields were felt to match the damage that had been inflicted to the crania of the dead; these implements, along with a bloodstained knife discovered in its hiding place under the mantle clock, are still on display at the Cherryvale Museum and the Kansas Museum of History (as the commercialization of Lizzie Borden, Jack the Ripper, and the Donners can attest, nothing has the power of a lurid folktale to eventually whitewash the past and draw in the tourist bucks).

And while some locals were arrested as middlemen who fenced valuables taken from murdered guests, the Benders themselves did not answer for their alleged involvement, nor were they ever brought to justice in a court of law. While there were rumors of their deaths at the hands of vigilantes, as well as tales of their escape to the badlands of Mexico, no proof was offered and no one stepped forward to claim the substantial reward money put forth by the authorities.

In fact, the trail grew cold quickly. The Benders disappeared, and were never seen again.

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[Copyright 2013 @ The Alienist’s Compendium]

Cotard’s Syndrome

“Yes, I’m warm, but things give off heat as they rot. And I suppose it is a pulse… but it’s a very weak pulse.”
~a former patient with Cotard’s Syndrome

Attending on a high-security forensic psychiatric ward has some perks for the curious of mind. The civil libertarians might not approve, but there is a little-realized facet of pre-trial evaluations that provides clinicians an opportunity to observe patients for far longer than would be the case in just about any other venue. You see, if a person is charged with a serious felony but is found incapable mentally of proceeding to trial, they will remain in a secure inpatient setting until such time that 1. they are restored to capacity to proceed, or 2. the charges are dropped. When the charge is, say, murder, prosecutors are reluctant to appear ‘soft on crime,’ but if the person is so mentally unstable that they might never be restored to capacity, you have a situation in which a person not convicted is nevertheless confined for indefinite periods of time in medico-legal limbo.

With 3d party payors wanting patients out the door in a matter of days, this limbo affords a clinician opportunities to observe pathology over a far longer span than would otherwise be possible in an inpatient setting. Just try getting Blue Cross Blue Shield to approve a hospital stay of fifteen years or more.

I will now dispel another fantasy held by many not involved in forensic psychiatric work: that it’s all like FBI profiling or CSI on television. It’s not. Much of it is routine and repetitive. Patients are admitted with symptoms of depression and anxiety (common), garden-variety schizophrenia (common), malingering and substance abuse (very common), and a smattering of less frequent conditions.

And then once in a very long while, perhaps a single time in a career, you see something astoundingly rare. It happened to me.

First some background: Jules Cotard, a former French army surgeon in the Franco-Prussian war who practiced at Hospice de la Salpetriere outside Paris, saw a female patient in 1880, whom he called Mademoiselle X. She held the belief that she was dead. Not a suicidal desire to die, mind you, but already dead. Patients with this particular condition maintain that they have died and, sometimes as an added delusion, are missing vital internal organs, an intact body, or a soul. They espouse being walking rotting corpses – totally utterly dead. Mdmse X had just such a presentation. She was convinced that she had no blood, no heart, and was a moldering cadaver. No amount of reassurance or production of evidence as to her actual state convinced her otherwise. She stopped eating – why would a corpse need to eat? – and eventually is said to have expired of starvation. Cotard called the condition le délire de négation, or nihilistic delusional state, but 21st century lay readers may know it better from media sensationalism as Walking Corpse Syndrome.

Delusions in general are challenging to understand and explain (and treat), especially to those in training or whose psychiatric patients to date have been middle class suburban neurotics on low-dose Prozac. A delusion is a fixed and unshakable belief that runs counter to reality and all evidence to the contrary. Delusions are insidious in that they usually do not appear overnight; there is almost always a prodromal phase in which the patient-to-be begins to focus on unusual ideas that might trigger some alarm amongst friends and family, but haven’t by that point reached the level where emergent psychiatric intervention is sought. Despite the detachment from reality, delusions do not involve visual or auditory hallucinations. While some delusions are fantastical (e.g., Martians have landed), others are entirely plausible (e.g., being followed), making their diagnosis difficult until the weight of evidence leaves no other choice. There are paranoid delusions – that spies or law enforcement are monitoring one’s actions. There are grandiose delusions – that one is famous and wealthy. There are erotic delusions – that a newscaster or movie actress is one’s secret lover. A delusional state likely drove John Hinckley to attempt to assassinate President Reagan. Delusional thoughts were reportedly evident in the suicide note left by the recent Washington Navy Yard shooter. Anna Anderson, the woman who claimed for decades to be Grand Duchess Anastasia of the House of Romanov, almost certainly suffered from delusions.

The beliefs espoused by those with Cotard’s Syndrome, in extremis, basically are no different. While Cotard’s Syndrome is not a freestanding diagnosis within the Diagnostic and Statistical Manual at present – possibly a reflection of its rarity – its psychotic presentation is solidly within the realm of the delusional. And while delusions of death are its hallmark, other aspects of the syndrome, such as the cessation of eating and bathing, or tactile hallucinations of worms eating the corpus, are unquestionably related. There is even one documented variant of a Cotard’s patient espousing immortality, premised on the belief that if he were dead but still able to talk and think, he must be a god. Go figure.

Cotard believed that there are two stages in the disease’s progression. For those more fortunate (?), the early phase, which was called germination, involves a psychotic depression with a fixation on hypochondriacal topics. If the patient is lucky, it will arrest there, and at least at present, with antidepressant medication and electroshock therapy, prognosis is guarded but not hopeless. Those who progress on the continuum, however, like Mdmse X, develop unremitting delusions of present-tense death, often resulting in a self-fulfilling prophesy of sorts.

And interestingly, Cotard was probably not the first person to recognize the condition. An English physician, Charles Bonnet, described the case of an elderly female patient in 1788. She had been hit by a sudden cold draught in the house, the story went, and instantly came to realize that she was dead. She insisted on being stretched out in a coffin and hosting a wake. Apparently she was fussing over the way her burial shawl was arranged during her own memorial. Once she fell asleep, her family moved her to bed, and with treatment that included the ingestion of ground precious stones and opium (!), she is said to have improved over time, but would still relapse every few months. Why this condition is not know as Bonnet’s Syndrome I am not certain, except that from the vantage point of two centuries, the elderly woman with the draught seems far more histrionic than do those with a profoundly neurovegetative state manifested in fulminant Cotard’s Syndrome.

I have searched the medical literature on this subject and found few scientific articles. Cotard’s Syndrome itself appears rare; however, somatic (bodily) delusions become more common if the diagnostic net is cast wider and other entities are included – these aren’t ‘pure’ Cotard’s Syndrome, but they share clinical features. For example, those with schizophrenia often have irrational thinking, although there is no evidence that their delusions are more likely to involve present-tense death. Bipolar disorder can produce psychosis at the extremes of mania and depression, but these symptoms clear when the patient returns to a euthymic, or ‘even keeled,’ state. Certain medications can effect profound mental status changes, but such suggests a transient toxic delirium and not a more intractable delusion (i.e., as far as we know, Cotard’s can’t be ‘fixed’ by dialysis and metabolic homeostasis alone). Strokes can manifest a state called asomatognosia, in which a patient loses awareness of parts of the anatomy on the afflicted side of the body. Traumatic head injuries can yield disorganized and delusional thoughts, as can subsequent or unrelated seizure activity, end-stage liver failure, tumors, dementia, and even severe migraines – but none of these are Cotard’s.

Almost nothing is known of the actual pathophysiology of Cotard’s, except that PET scans have revealed a markedly decreased level of glucose metabolism in the (admittedly few) patients with the condition who have been studied. The degree of decreased metabolism is similar to, but markedly more than, that seen in patients taking certain tranquilizers, or those under anesthesia or in vegetative states.

In many ways, Cotard’s Syndrome is related to Capgras Syndrome, since both are seen as disconnects in the parts of the brain that govern recognition and related emotional response. Capgras’ Syndrome is a delusional state in which a patient believes that familiar faces are actually those of imposters. If synapses in pertinent parts of a patient’s brain malfunction and this recognition system fails – what psychiatrists call derealization – one develops Capgras’ (if one is viewing others) or Cotard’s (if one is viewing self). Or at least that’s the theory.

In 26 years of clinical practice, I have only encountered once a patient with Cotard’s Syndrome. It was while I was attending on a long term forensic unit at a state psychiatric hospital. At the time I only had a vague recollection of what was Cotard’s; it’s not really a subject stressed in medical schools or residencies, being subsumed by the larger taxonomic umbrella of (generic) ‘delusional disorders.’ I remember my patient as an elderly black male of wiry build with short graying hair and, surprisingly, a ready smile when addressed. He was also in good physical health – he had no known history of head injuries, epilepsy, migraines, cardiac disease, cirrhosis, or malignancies. He also did not have schizophrenia, bipolar disorder, or dementia, and was not delirious while on my service. As a matter of fact, except for having little formal education, he seemed ‘normal’ on the surface if not always talkative.

Patients suffering dementing processes can often appear cognitively intact if an interview lacks depth; this is because these patients can initially cover their deficits with socially expected superficialities. The same can hold true for other psychiatric illnesses. In the case of my patient with Cotard’s, if one didn’t bring up his mortal condition, he could talk about ward activities and the weather and what he had seen on television without any problem. But if one brought up the state of his health, he’d say, in no uncertain terms, that he was dead. Psychological testing – repeated over time – did not show evidence of malingering or over-endorsement of symptoms, and this fact, along with his consistent clinical presentation over the years, suggested that he was the ‘real deal.’

And as with almost all other delusional disorders, if you engaged my patient in a discussion of his physical state, no matter how persuasive your logic, he had a ready explanation for why that just wasn’t so. Why did he eat and drink? Well, it was an activity he picked up while alive, one that he did now merely out of force of habit after more than 70 years. Why was his blood still liquid and red when drawn for labs? He hadn’t been dead long enough for it to have coagulated. Why did he sleep? He didn’t actually sleep – he just lay in bed with his eyes closed so that he could concentrate on the worms eating him. Why did he bathe? Corpses don’t need to bathe since they don’t sweat (the bathing part was accurate… he rarely attended to hygiene unless forced). And so on.

Treatment? Therein lies the problem. If delusions of death stem from a psychotic mood disorder, the treatment can include antidepressants, anticonvulsants, lithium, and shock therapy, with a fair prognosis. However, when the delusional symptoms are not caused by another underlying etiology, the response to treatment is often poor and incomplete. In my experience, antipsychotic medications, for example, render such a patient less likely to verbally express delusional thoughts, but the thoughts are still ‘in there’ – as was seemingly the case with my patient. Though I later moved to a new position in a different hospital, I have learned since that he’s still hospitalized. And still incapable of proceeding to trial. And still ‘dead.’

[Have an idea for a post topic? Want to be considered for a guest-author slot? Or better, perhaps you’d like to become a day-sponsor of this blog, and reach thousands of subscribers and Facebook fans? If so, please contact the Alienist at vadocdoc@outlook.com]

[Copyright 2013 @ The Alienist’s Compendium]