FreshMD

Personality disorders

As a resident doing my psychiatry rotation, I was trying to memorize the features of the different personality disorders. For example:

Histrionic personality disorder

• needs to be the centre of attention
• inappropriate sexually seductive or provocative behaviour
• rapidly shifting and shallow expression of emotions
• use of physical appearance to seek attention
• speech style is excessively impressionistic and lacking in detail
• dramatic, theatrical
• easily influenced by others or situations
• considers relationships to be more intimate than they actually are

and

Schizotypal personality disorder

• lack of close friends or confidants other than first-degree relatives
• excessive social anxiety
• odd beliefs or magical thinking
• strange manner of speech
• eccentric or peculiar appearance and behaviour
• ideas of reference (e.g. belief that messages are hidden for him/her in the newspaper)
• suspicious or paranoid ideas
• inappropriate emotions

*From the DSM-IV-TR

There are ten personality disorders. To make the studying easier, I devised an exercise where I considered my friends and family, one by one, and decided which personality disorder I would assign to them, if I were forced to pick one.

This was easier than I'd like to admit. Sometimes the difficulty lay in selecting only one diagnosis.

The process was so fascinating, I made the mistake of mentioning it to some friends that evening. Naturally they were clamouring to know what they were - schizoid? antisocial?

I chose my answers very carefully. Let's just say that I seem to have surrounded myself with narcissists and obsessive-compulsives.

Snow day

Superfetation

Superfetation is the fertilization and subsequent development of an ovum when a fetus is already present in the uterus, a result of fertilization of ova during different ovulatory cycles and yielding fetuses of different ages. (Superfecundation, remember, is the fertilization of different ova within the same cycle.)

In other words, you can be pregnant and conceive a second child. Or, as in this recent case, you can be pregnant with twins and conceive a third child.

Superfetation is extremely rare in humans. There are only a handful of cases reported in the medical literature, most with a difference of three or four weeks between fetuses. The babies are typically delivered together.

The case of the Italian woman who claimed to have conceived triplets three months into her singleton pregnancy impressed even medical professionals, although it turned out to be nothing more than a hoax.

So if you're disappointed after your first ultrasound that you're not carrying twins, take heart - the possibility is not completely ruled out.

Whistler

* I can't take any credit for the above baby. That's our friends' three-month-old.

We spent the weekend at Whistler with friends. With three kids apiece, we were evenly matched.

We decided beforehand to put aside any fantasies of skiing or dining out, and to focus on giving the kids a great time. We learned long ago that dragging kids along on expeditions geared for adult fun is an exercise in frustration. Far better to be resigned to devoting yourself to making your kids happy. This makes an unexpected hour to wander Whistler village alone that much more delicious.

And so the weekend involved sledding, late nights, swimming, movies, roasted marshmallows, a steady stream of snacks, some cherished periods of adult time, a limited number of meltdowns - thankfully only by the kids - and two minivans of happily exhausted adults and children winding home on Sunday evening.

Patients or clients?

At a meeting earlier this week, I noticed that the physicians used the term patients, while the administration invariably referred to clients.

Patient has its roots in the Latin patiens, meaning capable of enduring.

Client is from the Latin cliens, meaning dependent, and is defined as the party for which professional services are rendered.

So the first focuses on the experience of the treated person; the second sees that person only in relation to the professional providing service.

Wouldn't you want your doctor to see you as a patient?

When Auntie gives your five-year-old a Barbie

There were a few comments on this post regarding how to handle others giving your child toys you'd rather they didn't receive. I know parents who avoid Bratz dolls, Barbies, battery-operated toys or play guns. I dislike slutty princesses, poor-quality plastic items, and anything that produces obnoxious sounds. My friends and family have given my kids many fantastic toys, and I've only had reservations about a gift on a few occasions. Naturally, I've developed an approach:

• Be intentional about what toys you choose for your kids. If you put some thought into your selection of playthings, chances are others will pick up on your preferences. When I'm looking for a gift for someone else's child, I have a fairly good idea what, if any, standards my friends/family have, without them having spelled it out.
• I've seen a few birthday invitations with a polite request at the bottom that partygoers refrain from bringing certain gifts (e.g. toys related to violence or warfare).
• You could suggest items your child would appreciate for birthdays or Christmas.  I will admit, I don't supply ideas unless asked; it does feel a bit presumptuous to give an unprompted wishlist. However, I don't fault others for doing so. I like it when mothers give me some idea of what to shop for.
• Saskia has a Plan dollhouse, and Leif has the PlanCity road and rail system. If people know you have a collection started, they'll likely add to it. And you've made things simpler for them.
  

So, what if your preventive measures didn't work, and your five-year-old is given the toy you've been carefully passing over for years? This can get a bit tricky. I always appreciate the thoughtfulness and generosity behind a gift, and the recognize that the giver had the best of intentions. So I have never returned a gift, or forbidden my kids to play with it. I do, however, have a few strategies:

• I don't feel compelled to keep a gift given to my child forever. After a few months, when I find it in the corner of the bedroom, forgotten under a heap of dress up clothes, I might discard it by consigning, trading, donating or disposing of it. Consignment works particularly well, because you can purchase a different toy with the proceeds of the original one.
  
• I may put the toys in question in the car as going-out toys. If the Bratz doll is left behind in White Spot, problem solved. When the kids want to take toys to the beach, take the Barbie family.
• Some I put in the garage as outside toys. I don't worry about them getting lost in the garden, or sitting in the sandbox for weeks on end. And this reduces the number of requests to bring the 'good' toys outside.
• Any large, unsightly or noisy toys are stowed in the basement.

I realize this system will have to be adjusted as my kids grow older. But for now, for a six-, three- and one-year-old, it works well.

Before and after antiretroviral therapy

Courtesy Dr. Joep Lange

An HIV+ Romanian orphan, before and after seven months of antiretroviral medication.

One of the aspects of HIV care provision that I find rewarding is that most patients respond very well to treatment. Unfortunately, there are great disparities in the availability of HIV drugs worldwide, and the boy documented in the above photos only received antiretrovirals after extensive lobbying by Dr. Lange (previous president of the International AIDS Society) and his colleagues.

Flower Fairies

Illustrations by Cicely Mary Barker

I've been looking for an alternative to the slutty princess market that's been trying for years to foist itself on my six-year-old daughter. These beautiful, botanically-correct flower fairies by Cicely Mary Barker (1895 - 1973), an English illustrator, satisfy us both.

Larry Schweiger of the National Wildlife Federation wrote in this editorial, "Our children are disconnecting with nature . . . By the time they are seven years old, most youngsters have been exposed to more than 20,000 advertisements. They can identify 200 corporate logos, but they cannot identify the trees growing in their front yards."

We're working on rectifying that, and Barker's books of illustrations are a very pleasant way to begin.

Superfecundation

Superfecundation is the fertilization of two or more ova during the same ovulatory cycle, by separate coital acts. When the fertilization is by sperm from different fathers, it is called heteropaternal superfecundation.

In other words, fraternal twins can have different fathers.

According to this article in the medical literature, approximately 1 in 12 sets of dizygotic (fraternal) twins result from superfecundation.

The same paper (1993) estimates that 1 in 400 sets of fraternal twins born to married, white American women result from heteropaternal superfecundation.

Heteropaternal superfecundation has been suggested as an explanation for the "black and white" twins I wrote about here. There's been no official word on the mother's sexual history, or whether paternity tests were done, so it remains speculative.

And maybe the twins who married each other without realizing they were related had different fathers, and were merely half-siblings. Although I doubt that would have been much consolation.

Clarification

After feedback from a few people, including my husband who just returned from an extended business trip, I feel I should clarify the point of this post.

What I appreciated about that particular paragraph by Elizabeth Gilbert was the description of the many, many factors that influence one's disposition, not the reference to "getting laid". I included that last sentence because, well, it was part of the paragraph and to end with the comment about "yearning for God" would misrepresent Gilbert.

She clarifies in the next paragraph, "What a large number of factors constitute a single human being! How very many layers we operate on, and how very many influences we receive from our minds, our bodies, our histories, our families, our cities, our souls and our lunches!"

I can assure you that (a) my reveries over laundry very rarely involve sex and (b) I've never prescribed sex as an antidote for depression.

Does Skin So Soft have street value?

There was a theft at the clinic this week. A nurse's Avon samples were taken.

I just received a reassuring email that the lotions were recovered from a patient's backpack, sterilized, and put back in the lunch room where the staff could resume testing them.

All is well.

He may have a future writing advertising copy

As we passed Superstore this morning, Leif exclaimed, "I just love that store so much."

"You do?" I asked, taken aback by the depth of his feeling, and having nothing more than a superficial appreciation for the grocery store's pricing and convenience, myself. "Why?"

"Because I love my family," he replied softly.

The Albino Project

Photos by Pieter Hugo

I love medicine and photography, but there are many obstacles to combining the two.

These images are from Pieter Hugo's The Albino Project, a collection of photographs of mostly South Africans with albinism. (This is a partial collection, but more viewer-friendly and with text.)

I find them utterly compelling, and I'm trying to tease out why.

Obviously, it's startling to see blonde Africans with fair skin. But what's unusual is that you get to take a second and third look, and don't have to be surreptitious the way you would if you sighted them on the bus. You're given permission to stare.

Maybe it's the intimate, affable quality of the portraits.

Perhaps the intrigue lies in that there are so many! Who knows enough albinos for a series?

And who would have the nerve to line up two dozen African albinos and document them, passport style?

Pieter Hugo is a South African 31-year-old award-winning photographer with a varied body of work, much of it focused on the developing world. A good part of it is medicine-related, dealing with blindness, tuberculosis in Malawi, and Cape Town men who died of AIDS.

And if medicine isn't your thing, the images from The Hyena and other Men are nothing short of thrilling.

Photo by Pieter Hugo

Boy babysitters

While I was working with a psychiatrist as a resident, we had a discussion about child sexual abuse. He asked if I had children. Saskia was a year old at the time.

"As the father of three teenaged sons, I hate to say this," he advised. "But never let any boy or man babysit your daughter."

I find this tricky. I dislike a blanket exclusion of male babysitters; I have brothers and friends I trust completely. But evaluating babysitters for pedophilia risk on a case-by-case basis is even more discomfiting. Since most abuse is by relatives and family friends, simply excluding the neighbourhood boys from the babysitting roster misses the point.

So far, we've lucked out and found several batches of teenaged sisters who babysit for us regularly. But if they couldn't make it, and had a brother, and he offered to fill in . . .

It would be awkward, but I'd say no.

Depression

I'm reading Eat Pray Love by Elizabeth Gilbert. I always read with a pen, and mark passages that strike me as particularly well-written, poignant, interesting, relevant or beautiful. This book got a lot of ink marks.

As a physician who sees many depressed patients, and as a mother who tends to ruminate while doing laundry on her days home, I appreciated this paragraph:

"I became a student of my own depressed experience, trying to unthread its causes. What was the root of all this despair? Was it psychological? (Mom and Dad's fault?) Was it just temporal, a "bad time" in my life? (When the divorce ends, will the depression end with it?) Was it genetic? (Melancholy, called by many names, has run through my family for generations, along with its sad bride, Alcoholism.) Was it cultural? (Is this just the fallout of a postfeminist American career girl trying to find balance in an increasingly stressful and alienating urban world?) Was it astrological? . . . Was it artistic? (Don't creative people always suffer from depression because we're so supersensitive and special?) Was it evolutionary? . . . Was it karmic? . . . Was it hormonal? Dietary? Philosophical? Seasonal? Environmental? Was I tapping into a universal yearning for God? Did I have a chemical imbalance? Or did I just need to get laid?"

[Addendum - January 19, 2008]

Humour

I admire how much amusement kids can glean from the simplest things. Like most childhood traits, their sense of humour is remarkably intact, unsophisticated and pure.

Saskia and Leif reminded each other for days of Ariana’s accidental flick of the garburator switch under the kitchen sink. The terrified, guilty look on her face as she hurried from the room on her fat baby legs when the machine roared into action struck them as hilarious.

Last week I told Saskia and her seven-year-old cousin, Elle, how Leif had opened the closet door when he tried to leave his unfamiliar bedroom at Opa and Oma’s house. They shouted appreciatively.

Then I told the girls about Ariana’s behaviour at a restaurant earlier in the day. “She was bored, so I gave her the slice of lemon from my water glass,” I began. They waited expectantly. “She licked it and pulled a face.” They were delighted. “Then she put the lemon slice on the table and spanked it,” I concluded. I wasn’t disappointed. They laughed until they were breathless.

When they had finally composed themselves, Saskia squeaked, “Ariana spanked a lemon for being sour!” and they doubled over again.

I envy them.

Schmetterlingszauber

I want my own practice just so I can put this book in the waiting room.

Conny Wenk, a German photographer, has put out a book of photographs of her daughter Juliana, who has Down syndrome, and her two kindergarten friends.

Recently someone was telling me about a mutual friend who had given birth the day before. "She had the baby yesterday," she told me. "A girl. She weighed seven pounds, she's healthy, and they named her Allison." There was a pause, and she added, as if an afterthought: "One small glitch. The baby has Down syndrome."

I understand not wanting a medical diagnosis to colour a birth announcement, but to call Down syndrome a "small glitch" strikes me as absurd. I've met a proponent of changing the name of Down syndrome to Up syndrome - "because we should be more positive about it!" And I've encountered many descriptions of children who "by the way, happen to have an extra twenty-first chromosome."

I get it. Parents want their child to be seen first as a person of full worth, not a medical diagnosis. And in a society where Down syndrome is an accepted reason to end a pregnancy, I can understand the pressure on those who choose otherwise to emphasize their child's value.

But this carefully crafted minimization of the condition bothers me. And that's why I'm so pleased with my find. This collection of beautiful photos, of a gorgeous little girl giggling, applying nail polish and jumping on the bed with her friends, gives a quiet, fresh perspective on a child with Down syndrome.

The text is in German, so for all I know, Ms. Wenk ends the book with an afterword noting that, incidentally, her daughter has Trisomy 21. I hope not.

I couldn't find the book on Amazon, so I ordered it from the German Arbeitskreis Down-Syndrom (Down Syndrome Working Group). The emails beginning with 'Guten tag' and the package addressed to Frau Martina Scholtens were a nice bonus.

Ontario photos

Click here for the Flickr slideshow.

Human tails

A patient came in to see me about an abscess on her lower back. As she lay on her side on the exam table, I examined the area in question. "How long has this been bothering you?" I asked her, as I palpated the abscess. "My tail?" she asked, referring to a thick patch of dark hair a few centimetres higher up on her back. "I was born with it. And it doesn't bother me at all."

Photo from IndianPediatrics.net

By 1998, there had been 59 cases of human tails reported in the medical literature. True human tails consist of muscle, nerves, blood vessels, fat and connective tissue, and are covered by skin, which may be hairy. True tails result from the persistence of the embryonic tail, which normally lasts for four weeks and disappears as pregnancy progresses.

A pseudotail is a protrusion on the lower back from any other cause, such as a tumour or abnormality of the underlying vertebrae. About 1/3 of reported human tails are pseudotails.

(My patient did not have a tail or a pseudotail, but I wasn't going to argue with her choice of nomenclature for her caudal tuft of hair.)

A true tail can be as long as 13 cm. There have been pseudotails measuring as much as 33 cm.

Some tails can move.

In most cases, the tail is removed surgically at birth. 29% of human tails are associated with other malformations, usually spina bifida, so thorough investigations are necessary.

There are several reports from India of patients with tails who refused surgery because of the positive cultural ramifications. Chandre Oram, an Indian tea estate worker, has a 33-cm tail and is revered as an incarnation of Hanuman, the Hindu monkey god. Little Bajrangbali, pictured below, has a 10-cm tail and is displayed at temples across India.

Photo from www.aliraqi.org

Believe me when I tell you that Googling "image human tail" is not for the faint of heart.

Now, I wonder what the likelihood is of being born with a tail and horns?