Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Saturday, April 26, 2008
Now I Remember
So in my post from yesterday I talked about the normal process of memory and forgetting. Right after I published that post I started thinking about all the weird little things that I remember.
In order to be a doctor you have to have a pretty good memory. You start out by memorizing muscles and bones and nerves and blood vessels, and work your way into the body by memorizing types of cells and cell processes and biochemical reactions. (How many of you remember how many molecules of ATP are produced in the Kreb's cycle?) The comedian who played Father Guido Sarducci on Saturday Night Live used to have this bit where he'd advertise for the Five Minute College. By sending him lots of money and taking his Five Minute College course, you could get a college degree while learning everything a college graduate remembers five minutes after leaving college.
I'm always surprised by the little factoids and trivia I remember, both in day-to-day life and from college days decades ago. I remember my friend's apartment number because it's the same as the year Jamestown was founded. I remember my childhood phone number (OK, that's an easy one---it's two digits repeated two or three times) as well as the addresses for all the apartments I've ever lived in.
Remembering things too well is rarely a problem for people. When it happens it's usually in the context of unpleasant or horrible memories, memories that intrude on day-to-day life and are upsetting or interfere with one's ability to function, as in post-traumatic stress disorder. These situations are usually managed with therapy, although now people are also experimenting with the use of medications to prevent the formation of intrusive memories after traumatic events. This is still too experimental to be practically useful, however.
Of course, we know that memory is not always a reliable thing. We remember childhood events differently than our older siblings, or not at all. In the 1980's following years of a movement for the treatment of trauma survivors we learned both that bad memories can be repressed, but also they can be created through false memory syndrome. The amazing thing is that false memories can be just as convincing to the individual as real ones.
Speaking of false memory syndrome, here's a practical example. When I started writing this post I was feeling rather pleased with myself that I remembered how many ATP's were produced by the Kreb's cycle. I was wrong. See if your memory is better than mine by checking out this link here.
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Why does that finger look detached?
And I've no clue about the Kreb's cycle, seems I had to learn it way to many times and oh....
Roy wants to know if we can meet earlier tomorrow. He told me to ask you.
On the surface, I find the thought of preventing the formation of memories (traumatic or otherwise) to be repugnant. It's experiencing, working through, and ultimately making meaning of what life deals us that defines the human condition.
Thanks for the nostalgia. I got 50% on your quiz... "36" is a number I remember for the Kreb's cycle, but I now realize it is not the # of ATP molecules (what is it?).
I think Pink has it wrong. Using this logic, we also shouldn't prevent the formation of myocardial ischemia, which is a life experience we should work thru. Preventing the formation of pathologic traumatic memories (like the ones which prevent otherwise logical people from using an elevator or getting in a car) is a laudable goal. The sticky part with this would be if we could remove select memories as easy as deleting a file from a hard drive. That's where the sci-fi movie aspect gets creepy.
I am with Dr. Pink Freud. I prefer working through my "stuff" to taking drugs and I certainly would refuse a post-trauma pill. What would it be like to have lived through the World Trade Center collapse ... and have forgotten all about it? I just talked to a woman ysterday who has a 40 year old son who was in the second tower to be hit. When the first tower was hit he and a few of his male buddies started running down the stairs from the 93 floor. When they got below the 50th floor their tower was hit ... above where they were and they managed to run fast enough to get out. Would he want to forget that? Perhaps, but instead he has moved further south in NJ, got a job away from NYC and rejoices in being alive. I'd rather that for myself.
KREB'S CYCLE: It is possible that I am your only reader who studied the Kreb's cycle 2 days ago. I was a geology major and don't recall ever having studied it before, but I am trying to learn enough biology to pass the Single Subject Biology specialty exam in California so I can hopefully get an "intern" teaching job in fall (which will be concurrent with my teaching credential program). Apparently the school system has little use for a geo major and would LOVE it if I can qualify to teach bio.
That link was WONDERFUL. It's a much better description of the Kreb's cycle than what's in the book I have, so I will go read it and hope MY memory of the Kreb's cycle is good enough to get me through the May 17th exam.
Dinah: I may be able to meet earlier, depending on how early.
Pink: I agree. My patient have enough trouble learning from experience. I can imagine what would happen if they could take a pill and wipe out all memory of what incarcertion was like.
Roy: You're good. I only got 12%. I think there's a difference between preventing trauma (myocardial infarction) and preventing traumatic pathological memories. Not all traumatic memories, while unpleasant, are pathological. I would venture to say that most aren't. And there's a lot of individual variation in one's ability to adapt to trauma. Would this mean that someone who has adapted to trauma and is not disabled or impaired by their memories shouldn't be given the treatment? How would one decide?
TP: I'm glad my link was helpful. I like supporting teachers :)
Regarding the 5-Minute College:
Funny concept, but the way I always looked at it was that in college we learn HOW to learn so later in life we can teach ourselves anything. In science graduate school we learn how to do research. It does not matter if we stick with the same field of study or continue in the same field of research. We have learned the process and how to think critically.
No way I'm taking any test.
So I have mixed feelings about the drugs to erase memory. Certainly our society values growth through suffering, and there is something very creepy about the idea of using a pill to wipe out the emotions of normal human challenges...say a romantic breakup....
But it's a judgment call that I don't ever feel comfortable with, our same issue over and over, to say it's Wrong to use meds to eliminate certain types of suffering.
TP: you ask if the guy in the towers would want to forget, and implicit in your comment is the idea that you would not if you were there, but I think to really have an answer to the question, you'd have to ask someone who Was there, and if you asked 12 people who were there, you might get 12 answers.
Clink prefers working through her stuff and would not take a post trauma pill. How do you know? I mean maybe you do, maybe you've been through some horrendous trauma and never mentioned it to, but I guess I don't feel comfortable in my untraumatized life saying that someone who's been through some awful.... held at gunpoint, tortured for hours, then gang raped by 6 brutes...is "wrong" to want something, if something is available, to lessen the traumatic sequelae.
It's a matter of each person's tolerance for "trauma" and susceptibility to lingering sequelae, and a judgement call as to where the lines should be. I get very upset when I take those tests that prove that I don't remember anything from all those years of higher education and I think I need something to get me through getting those score results. We wouldn't want my self-esteem to suffer any.
Oy. Please don't post assumptions about me or put words into my mouth, particularly when the examples you use are extreme.
I said in my previous comment that even the definition of trauma is pretty broad (which is one of the problems we've had with the expanding use of the PTSD diagnosis in litigation). Certainly the example you posted would be traumatic for anyone, but there's a large grey area. A car accident could be traumatic, but what kind of car accident? A fender bender with no injuries? I've had a couple of those that left me shaking. What about a conflict with a neighbor? Again, for some people traumatic but for some people (umm...people who remain nameless who may like to debate things) maybe it's all in a day's work.
The point that I was trying to make that the decision to treat or not treat (or for the health care system, to pay for treatment) is a difficult one to make. As you occasionally and correctly point out, there are no bright line decision points in life or psychiatry. It's the discussion itself that's the important thing.
Oh, that's a finger with a ribbon on it, not a diploma. Doh!
So, Dinah stated my thoughts perfectly. What is considered "pathologic" would have to vary from person to person. For example, I can think of no memories that I would want "erased". But what is being discussed of late is NOT a complete erasure of a memory, but de-emphasizing the memory so that it is not tied so strongly to the amygdala's fear circuitry.
Thinking about PTSD, for example, if a 9/11 NYC survivor reacts with extreme panic and fear everytime she hears a plane pass by overhead, such that it causes her extreme distress and avoidance, then I would call that a pathologic memory. The idea is that a drug would not "erase" the memory of 9/11. It would de-link the memory of "airplane noise" from the fear response. This is exactly what happens with deconditioning, desensitization, and CBT. The idea is to have a drug that would do the same thing, or even prevent such a pathologic connection to occur in the first place, while having mimimal side effects and not messing up "normal" memories.
I think folks are assuming that we have too
A really towering paper in the Posttraumatic Stress Disorder literature deals with the excessive stickiness of memory in PTSD. The data comprises case reports of the month long use of Cortisol (Cortef) 10 mg a day, this is a low dose of glucocorticoid, by Amanda Aerni. R. Greene at the Dallas VA has a nice paper using rats in a related paper; impressive statistics in the latter.
(Um... maybe I shouldn't post this on the internet, but I can't quite resist the urge right now. If I delete it later, it's because I came to my senses. ;) ).
Um... what Roy said. I once did a c-section under an unsuccessful local (read: no) anesthesia. It is a terrible thing to do to another person (although it saved a baby that would otherwise have died, the babies pH at birth was 6.8 and it did well).
It was months (maybe 6) before I could do a c-section with the residents without feeling awful and vomitting afterwards. Heck, it was months before I could sleep through the night. I almost quit my job, because it was so hard for me to tolerate doing it for a while. The whole story is kind of long, but eventually, I was treated for PTSD associated with this event. It was most of a year before I felt even mostly normal.
I think what they're talking about is not erasing memories. It's lessening the traumatic impact. And let me tell you, if someone had, say, told me to take 2 weeks of propranolol or cortisol, or whatever to lessen the pain this event caused me (and it was considerable. Some days I feel like I deserve it for what I did, but more and more I don't; my shrink and I have an ongoing debate, she says it was a traumatic event, I say I was the one inflicting the trauma. So, whether this counts as trauma or not, I'm not really sure, but my shrink says it does), I would really hope that I would have followed their recomendation, because that one event very nearly changed the entire tragectory of my life.
I wouldn't wish the memory away, because there were some lessons in there, but it might have been nice if the price hadn't been quite so high.
Also, if experiencing trauma and "working through it" somehow make one a better person, could the same also be said of uncomfortable procedures? Should we stop giving Versed and Fentanyl with D&Cs or even with a colonoscopy because enduring the cramping that some people feel despite the block will make them tougher and/or stronger? I don't think that's such a good argument. I don't think that there's that much of a separation between physical and mental pain.
MWAK: It's like you're seeing into the future (or the past), our entire next podcast (done yesterday) is on this subject (and hello to Dr. Pink Freud, too).
I want to know if the mom had PTSD.
Seems like in this one you would have "lost" either way-- does the surgeon get PTSD if you Don't do the quick C-S and the baby dies?
anon: (who I'm guessing is dinah, clink, or roy from the podcast talk) I couldn't quite decide whether to leave the comment up there or not, but since it seems relevant, maybe I'll leave it. Part of me can't even believe I brought it up. I thought about making it an anon comment, but I figured people would figure it out anyway.
Word has it that the mom's ok (although suing the anesthesia department for failure to show up for an emergency c-section, I can't say I blame her. I wish I could kick the anesthesiologist who didn't show up in the groin (he was supposed to be there, he was supposed to be available, and there wasn't even another surgery going on that night). That pregnancy was a nightmare for her in a number of HIPPA non-disclosable ways.
Oxytocin, seems to take some of the badness of the memory of pain away (people seem to regularly forget how bad labor is, or remember it as "not that bad").
I don't think surgeons get PTSD from failure to do a c-section. One of the um.. issues.. with my memory of the experience is that parts of it (like being soaked with blood, how the blood smelled, the terrible way the patient screamed and knowing that if we (junior resident and myself) didn't keep going, the baby would die are just so vivid, and other memories are really sort of blurred and indistinct it almost feels like the normal memory mechanism of my brain kind of got overwhelmed or short circuited. It's felt like it's encoded in my brain abnormally.
What people do do when they make a bad call and the baby dies is get depressed. Sometimes really, really depressed. Our residency once worried that a string of bad outcomes and bad cases had destroyed our morale, and so they decided to start sending the labor and delivery teams to group therapy sessions. It was a nice attempt, although not particularly successful, it made people feel like the residency program director cared. The therapist who led the group therapy sessions actually tracked me down in the week following that c-section to
check in with me (he was nice, but all I really wanted at that point was for everybody to leave me alone).
I had an attending who got really depressed when he made what seemed like a reasonable decision at the time and the baby died. He was so depressed he couldn't work for quite a while... And sure, he probably had a biological predisposition, but having a baby die on you like that totally destroys your self esteem and the illusion that if you can just be a good enough doctor bad stuff that seems preventable won't happen to your patients. You start to think of yourself as, "I'm the jerk that let Ms.Nice's baby die, and I could have prevented it but I didn't do the right thing". Different people have differing abilities to say, "I did my best" and move on. And I think that the ability to say that might be somewhat protective from medicine-induced-psychic injury. for lack of a better term.
Do any of these ramblings make sense?
[Heck at this point, I might as well post about it on my blog]
Thanks, Midwife for all your thoughtful comments. It helped me to better understand how it feels to have PTSD and what it means to be a doctor.
yeah sure give me a pill to delink the memory from the fear response or however they call it. the memory itself remains but my blood pressure won't go haywire, i won't have nightmare, daymares, jump all the time, i won't have the classic ptsd symptoms. i will just have the memory which will still be a lousy one to have but will not have physiological effects and i will have a more normal life. the reason i would say yes is because i already take pills meant to help calm down (the drugs don't work) and who doesn't know self medicators using alcohol to achieve the effect of blocking the memory or trying to go numb? it would be a whole lot better to take something to delink the memory from the trauma centers of the brain. it doesn't get erased. i think of it as making it more like now you have the same memory as someone who went through the same event but did not develop the ptsd symptoms. if that helps me function then great. i would view it no differently that insulin for diabetes or lithium for bipolar or srris for depression. we don't say to someone who is depressed, you need to feel the pain and run with it. maybe some people think we should say that but generally depressed people get treated.as to clink's question of how one would decide if someone who has adapted to a traumatic memory should or should or should not get the "treatment", i think that if they have adapted then the memory is no longer is traumatic for them. they retain a memory of a traumatic event but they are no longer traumtized by it, so for what condition would they require treatment? the whole notion of working through and finding meaning has lots its appeal after all these years.
I took the quiz and got 100%! Of course it probably helps that I am currently studying for both my Chem and microbiology finals. :P
As for pathological traumatic memories...I'd take a pill in a split second if it would help. My trauma was far too long ago though.
The number of ATPs produced in the Kreb's cycle changed about 10 or 15 years ago.. well the number produced didn't change, just the official number. So you may not have been wrong.
I'm always surprised by the discussion of the so-called "unreliability" of memory, without taking into account some of the more astonishing feats of memory, such as those employed by "autistic savants" whose memory capabilities defy explanation. Instances of memorization of entire numerical listings, being able to draw pictures of places seen only once, of individuals playing entire symphonies from memory without need for the score, children who express seemingly spontaneous aptitudes without having been taught - all examples of exemplary memory that defies the prevailing belief that the process of memory is "unreliable." For most of us, memory waxes and wanes for any number of reasons.
When it comes to trauma, most memory is accurate, though some details may be forgotten with the passage of time, nature of the event, age at occurrence, etc. It is possible to forget, and then remember, even non-traumatic memories, such as when I recollected going snow-shoeing as a child after seeing a picture of myself that I had previously completely forgotten. I remember "too well" my own traumatic memories-- better than I would like--but I don't know that I would "drink of the cup of forgetfulness" if I could (I believe there is wisdom to be gained even from the horrible events of our lives.)
In the case of "false memory" I don't believe one can be "implanted" with the memory of a trauma on the scale of sexual abuse when equated with a "suggested memory" of being "lost in a mall", which, while potentially frightening, is hardly on the same scale as a memory of abuse. It takes a certain amount of suggestibility for someone to be convinced of experiencing something they did not. Actual cases of "FMS" as such are few and far between.
I think when it comes to memory we still have much left to learn.
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