Sanitized For Your Protection

When I was in medical school they taught us that epidemics of infectious diseases were particularly likely to break out in public institutions like schools, colleges, correctional facilities, dormitories and military barracks. When you consider all the infectious illnesses a person could catch in prison---methicillin-resistant staph or drug resistant tuberculosis or hepatitis or HIV---I guess the common cold is pretty benign. Nevertheless, I take precautions to keep from getting sick and to keep it from spreading to others.

This actually isn't as easy as it sounds. Alcohol-based hand sanitizers are contraband and I have to provide my own kleenexes (Puffs only, thank you, with lotion). There is soap in the bathroom, if you have a key to get into the bathroom. I keep a can of Lysol by my desk. When I see an inmate who has a partcularly nasty cold I run down the hallway spraying doorknobs and swabbing them down with tissues in the hopes that even if I don't prevent the cold completely maybe I can at least minimize the viral load a bit. I make look a bit paranoid doing it, but it seems to work. I can't remember the last time I had a cold (although my pneumonia last January was particularly nasty).

I wish all infectious agents were that easy to control within the institution. Demoralization is the most infectious agent of all, and the toughest to treat once an outbreak starts. I wish Lysol would work for that.

How This Shrink Picks A Sleep Medication

I have more to say about sleep medications. But I have a lot less to say about choosing a sleep medication than I do about choosing an anti-depressant, and my thinking on this is a lot less structured.

Everyone who wants medication to help them sleep gets a talk about the obvious sleep hygiene issues. Here are the basics:
-- Choose a 7 hour period during which you'd like to sleep. Keep it the same everyday, for example, midnight to 7 am, but the exact hours aren't important. The regularity is. Set an alarm.
--Don't nap.
--Don't watch TV or do anything else interesting in bed (sleep and sex, that's it)
--No caffeine after 2 pm. And not much before that. That includes caffeinated soda and iced tea and sadly, chocolate.
--Exercise regularly, preferably 3 hours before you go to bed, but absolutely no closer to bedtime.
--Limit alcohol, and don't drink it near bedtime, it screws up your sleep architecture.
--If you have sleep apnea, use your CPAP machine. Really.

No one follows these recommendations, at least not when I make them.
Linda, the self-proclaimed sleep Nazi, would add: No Screens of any kind after 11 pm for adults and 10 pm for kids-- no computers, TV, video games. Even I'm glad I don't live at her house.

I prescribe sleep medications frequently, insomnia's a common complaint. Sometimes I feel strongly that someone should take a sleep medication-- disturbed sleep goes hand-in-hand with affective (mood) disorders and in patients subject to manic episodes, sleep is really important and I worry that poor sleep habits might either announce or precipitate an episode. Often, though, I feel like it's not the end of the world if every night's sleep is not perfect (great blogging gets done in those wee hours), and that some people are too quick to look to pills to fix problems. I'm probably going to get blasted for that one.

Sleep issues take on a life of their own. People get anxious about not sleeping and it builds on itself. They have all sorts of expectations about how much sleep they need or should have-- one patient was beside herself because she was only sleeping 6 hours a night and felt she needed 8 to 9 hours. Maybe she was right, but when I suggested that maybe she only needed 6 hours and that's why she was waking up, she felt I was dismissive and she found another doc. Another patient said he was greatly relieved when I told him his body was getting rest by just lying there quietly, he stopped worrying so much, and his sleep improved (plus, he turned on his CPAP machine).

All medications have the potential for side effects and adverse effects. Sleep medications are no exception. And many sleep medications are addictive and many patients insist they won't become addicted. And even folks who don't become addicted in an up-the-dose, abuse-the-med kind of way, they get habit-forming, whatever that means, and there are people who will end up taking a pill to sleep every night of their lives and won't hear of even trying to stop the medicine.

So my non-scientific, mostly random method of picking a sleep medication:

If the patient presents with depression, I hope that as the depression resolves, the sleep disturbance will resolve. Some anti-depressants are so sedating (TCAs, Remeron, Serzone, Trazodone) that they are effectively sleeping pills. Other times the anti-depressant, especially SSRIs, cause the sleep disturbance.

Trazodone. It works well in combination with SSRI's. It's cheap. It's not addictive. It's easy to stop. The down side: the fear of priapism and there have been case reports of patients who need surgical intervention. Ouch. The other downside: it doesn't always work, even in escalating doses. Or, it works but patients complain of feeling drugged for hours after waking up. When it's good, it's good.


If trazodone doesn't work or isn't tolerated, and there is no history of substance abuse (particularly of issues with alcohol/benzos), then I try Ambien. This usually works, and it doesn't have a hangover. At least it works for a while, some people get tolerant to it's effects. And some people never want to stop taking it. It's theoretically not very addictive, but it does hit those same benzodiazepine receptors.

If there's a history of substance abuse, I may try visteril. This works only rarely. Once someone has had extended exposure to alcohol or benzodiazepines, it's hard to knock them out.

If visteril doesn't work, I try Rozerem, even though I hate the Abe Lincoln/Beaver advertising campaign, and even though it costs a small fortune, and even though it did terribly on our survey. It does seem to work.

Sometimes I use seroquel or zyprexa. These work, though they have that same effect of leaving some people feeling groggy in the A.M. With all the concern about how these medications are linked with diabetes and lipid disorders, I use low-doses, as needed only for the short-term, and I don't prescribe it as quickly as I used to. Unlike many sleep medications, these are fairly easy to stop.

If there's no history of substance abuse, if the patient is a light social drinker with no history of abuse, then I may try ativan or valium for a short term issue. Restoril works well, though with it's long half-life, it's always a bit surprising that people don't feel groggy on this the next day.

I've never prescribed Sonata, and the first and only patient I gave Lunesta to complained of a horrible taste in her mouth.

With those thoughts, Good Night, Sleep Tight, Don't let the Bed Bugs bite.

Human Sacrifice in Ancient Moche Culture

My Three Shrinks (along with a high school English teacher friend of Dinah's) went to a lecture today at the Walters Art Museum entitled "Human Sacrifice, Power, and Ritual in Moche Society and Visual Culture," by Prof. Steve Bourget.

This was a nice thing to do on a Saturday afternoon. He started out with a picture of Freud, and a quote from him, which said something to the effect that 'sacrifice is the cornerstone of the creation of society'. Before long, we were treated to pictures of pottery and other archeological findings depicting the South American Moche culture (~450-700 A.D.), which included human sacrifice as part of their beliefs, and also as a form of social control.

As depicted in the image above, you can see two fellas at the bottom with their blood being drained from their neck by tribe elders, dressed in various animal-like garb. The blood is put in a cup, which is being passed around the gang at the top. It is not certain whether the blood was drank, but it was used to pigment various pieces of artwork.

Here's the interesting thing. Various lines of evidence points to the conclusion that the Moche sacrifices were used as rituals in response to El Nino-related changes in weather and ocean conditions.

Makes me wonder how much of what we are doing to reduce carbon emissions amounts to ritual sacrifices to increase the perception that we are in control of Mother Nature's ecological cycles.

What's it have to do with psychiatry? I'm sure you can find something in this (I didn't even mention all the penises and the talk about the role of men ("domesticated dogs") and women (a "wild" quality due to their menstrual cycles, which may have been linked to lunar cycles).

It's A Tough Job But Somebody's Gotta Hew It

Human Sacrifice, Power, and Ritual in Moche Society and Visual Culture

[Note: Roy beat me to this topic by a few mere seconds.]

My fellow bloggers are such good friends. They didn't even blink when I invited them to go to a lecture on human sacrifice with me. It was fascinating. The speaker, Steve Bourget, worked for several years on an archeological expedition in Peru involving the Moche people who practiced human sacrifice from 200 to 700 A.D.

Human sacrifice was used to reinforce the political power of rulers by linking them with gods and the priest caste who led the sacrificial ceremony. The victims were prisoners-of-war, sometimes hundreds at a time, who were led nude to the ceremonial site. They were killed by blunt head trauma using a club-like tool or by throat laceration. Many murals and other forms of Moche artwork depicted the killing as being done by humans dressed like animals (foxes or feline characters---like Tony the Psycho kitty?) who would collect the blood in a cup and pass it to the ruler god-figures. The corpses of the victims were defleshed and the skeletons were laid out symmetrically in patterns that seemed to hold some unknown meaning for the culture. Bourget theorized that the sacrifices were used to reset the natural order of the Moche world, particularly during times of heavy El Nino storm seasons when mud would flood the temples and the seas would team with creatures not usually seen in the region.

And then there was the penis issue. (C'mon, it's a psychiatry blog. You're going to see the word 'penis' eventually.) All of the sacrificial victims were men who were depicted on ceramic ceremonial vessels and on murals as being led to the slaughter with erect penises. Guys, correct me if I'm wrong but I would expect imminent death to be a bit of a challenge to the performance issue. I'm guessing the pottery artists were taking a bit of license here. Anyway, after the sacrifice the pottery vessels with the victims' depictions were broken and the fragments scattered about the burial site. The only parts of the vessel left intact were the little pottery penises. Being good academicians, these were counted and reported as the MNP (minimum number of penises) for each archeological site. Roy seemed particularly fascinated by this. Dinah and I were too busy chortling.

Women were nowhere to be seen anywhere in the sacrificial scenes or ceremonies. Bourget explained the female role was largely featured in the fertility iconography, which made sense. We didn't stay through the whole question-and-answer session to learn if this involved any little ceramic breasts.

So that's how we spent the afternoon. I'm grateful to my friends for sacrificing their time to be with me. Especially Roy. After today I think he may not mind being under the floorboards with all of his ceramics intact.