Family, friends and colleagues

Gladys Berejiklian & Jack Dikian

Welcome to the Loony Bin

Welcome to the Loony Bin tracks attitudes and approaches in psychiatry and the law over 55 years. The cases illustrate miraculous cures as well as blundering repetition of harmful excesses. Bell's book (autobiography) is certainly does not shun from calling the whatever, whatever. For decades he has taken iconoclastic and often unfashionable positions in relation to what he has regarded as fads and unscientific trends of the day.

Dr David Bell is a well known Sydney neuro-psychiatrist, who has run a psychiatric research unit, developed a therapeutic community, pioneered addiction rehabilitation, been a driving force in forensic studies.

The paradox of voting

I’m no political commentator, not even a columnist. This isn’t yet another piece pretending to make meaning of prevailing political winds. Instead, I wanted to weigh-in on something more paradoxical than even our continued, albeit weary, belief in the goodness of our political system - compulsory voting. After all, we are only one of a small number of countries (22) that have us turn-up to vote. Other nations in this small but noteworthy club include; The Congo, Costa Rica, Ecuador, Honduras Uruguay, you get the picture. But does compulsory voting really lead to a fairer more democratic system? This is a particularly pertinent question when election results are extremely tight.

As far back as the late 18th century, French philosopher, mathematician, and early political scientist Marquis de Condorcet described what is known as the paradox of voting. Marquis de Condorcet noted that collective preferences for a cause, an ideology, a political party can be cyclic rather than transitive despite the achievements of the incumbent. This is so even when the preferences of individual voters are not cyclic. The conundrum arises because it means that majority wishes can be in conflict with each other. This occurs because the conflicting majorities are each made up of different, albeit large groups of individuals polarised in a political faith, however lacking real and practical ability to govern in their own right.

If we fast track to the mid-1970s the American economist Anthony Downs posited the paradox of voting; here the closeness of an election result coupled with voter self-interest can explain significant elements of political life.  Downs showed that in democracies the aggregate distribution of political opinion forces political parties in democracies to adopt more centrist positions. Note Malcolm Turnbull’s immediate attraction of less conservative voters.

Downs’ paradox of voting is that for a balanced, self-interested voter, the costs of voting will normally exceed the expected benefits. However, because the chance of exercising the pivotal vote is minuscule compared to the anticipated benefits of the different possible outcomes, the expected benefits of voting are less than the costs. Again, this paradox is acutely germane to elections like the one we just had – ones where a small number of votes tips the scale one way or the other. Suffice to say, the fact that people vote at all is a problem for those juggling good economics management and political longevity – read the self-interested politician.

Fermat's Last Theorem - a Tree house of Horror

The popularity of The Simpsons is well known. It is after all the longest-running sitcom of all time. It’s canny; it’s also one of the most literate television programs on air - containing many references to subject matter and scholars from various academic fields. One of the instances of mathematics appears in the "Treehouse of Horror VI" episode.

The equation 1782¹² +1841¹² =1922¹² is visible, just as the dimension begins to collapse. The joke is that the twelfth root of the sum does evaluate to 1922 due to rounding errors when entered into most handheld calculators; notice that the left hand side is odd, while 1922¹² is even, so the equality cannot hold. Instead of 1922, it is approximately 1921.99999996.

Some will recognize this as Fermat's Last Theorem. The theorem states that no three positive integers a, b, and c satisfy the equation aⁿ + bⁿ = cⁿ for any integer value of n greater than two. You may also know this is one of the most famous math problems in history, as it remained unsolved for well over 300 years.

In the margin of his copy of a book by Diophantus, Pierre de Fermat wrote that it is possible to have a square be the sum of two squares, but that a cube can not be the sum of two cubes, nor a fourth power be a sum of two fourth powers, and so on.

Given that there are infinitely many possible numbers to check it was quite a claim, but Fermat was absolutely sure that no numbers fitted the equation because he had a logical watertight argument. Sadly, he never wrote down his proof. Instead, in the margin of a book, he left a tantalizing note in Latin: “I have a truly marvellous demonstration of this proposition which this margin is too narrow to contain.”

Although this is easily stated, it has proved to be one of the most puzzling problems in the whole history of mathematics. Long after all the other statements made by Fermat had been either proved or disproved, this remained.

The correct proof came in May 1995 by Andrew Wiles. Wiles had stumbled upon the last theorem as a 10-year-old and then spent the next 30 years working on the problem. A childhood dream evolved into an adult obsession, and when he eventually figured out a possible strategy for proving Fermat’s riddle, he worked in secrecy for seven years before revealing his 200-page proof.

The proof ultimately uses many techniques from algebraic geometry and number theory, and has many ramifications in these branches of mathematics. It also uses standard constructions of modern algebraic geometry, such as the category of schemes and Iwasawa theory, and other 20th-century techniques not available to Fermat.

Of course there are still problems out there to solve. In order to celebrate mathematics in the new millennium, The Clay Mathematics Institute of Cambridge, Massachusetts established seven Prize Problems. The Prizes were conceived to record some of the most difficult problems with which mathematicians were grappling. There is a $1 million reward for each of these so-called Millennium Problems.

Of the original seven Millennium Prize Problems set by the Clay Mathematics Institute, six have yet to be solved. These are:

• P versus NP
• Hodge conjecture
• Riemann hypothesis
• Yang–Mills existence and mass gap
• Navier–Stokes existence and smoothness
• Birch and Swinnerton-Dyer conjecture

Social networks and increases in anxiety about motherhood.

Research from Ohio State University may make new moms reconsider why they use Social Networks to post about their children – particularly the impact of frequent posting by some and increases in anxiety about motherhood.
The results (the study has some with important limitations) published in Sex Roles, found that when women felt more societal pressure to be perfect mothers and viewed motherhood as central to their identity, they were more likely to share child-related updates and photos. The majority of mums in the study did use their baby's image as a profile photo at some point.

The mothers who strove for perfection as parents and sought external validation for their maternal role also expressed stronger emotional responses — both positive and negative — to the frequency and nature of their friends' likes and comments.
That relationship with Facebook may have come at a cost. Nine months after giving birth, those same mothers reported more depressive symptoms like having a poor appetite, not being able to shake off the blues and experiencing restless sleep.

The study couldn't pinpoint a cause-and-effect dynamic between a new mum's desire for validation, her increased Facebook use and a greater risk for symptoms of depression, but the researchers believe there could be a direct link.

Like with any personal social media post, users are trying to carefully craft their identity. New mothers, in particular, encounter unyielding expectations about how they should behave, which can feel magnified on a platform like Facebook. They may feel pressure to adhere to impossibly high parenting standards, and turn to Facebook for both support in meeting those expectations and validation that they're fulfilling a stereotypical maternal role.

Incidence of psychiatric diagnoses in offspring prenatally exposed to SSRIs

A recent article in the Journal of the American Academy of Child and Adolescent Psychiatry presents a study looking at prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) and associated increased rates of depression diagnoses in early adolescence. The report stresses that these findings are preliminary and should not be construed to change clinical practice.

The study is the first to investigate the incidence of psychiatric diagnoses in offspring prenatally exposed to SSRIs as far out as adolescence, noting however the vital importance of treating maternal depression, which can have significant adverse effects on offspring. Untreated maternal depression has been shown to increase risks of several perinatal outcomes including preterm birth, delivery by C-section, and bleeding during delivery.

Researchers used Finnish national birth registry data to determine the cumulative incidence of depression, anxiety disorders, autism spectrum disorder, and attention-deficit/hyperactivity disorder in the offspring of four groups of mother-offspring dyads: mothers exposed to SSRIs during pregnancy, mothers exposed to psychiatric disorder but not to antidepressants, mothers who used SSRIs only before pregnancy), and children of mothers unexposed to either antidepressants or psychiatric disorders.

They found the cumulative incidence of depression among offspring exposed prenatally to SSRIs was 8.2% by age 14.9 years, compared with 1.9% in the psychiatric disorder/no medication group and 2.8% in the SSRI-discontinued group. In contrast, SSRI prenatal exposure was not associated with an increased risk of autism spectrum disorder, ADHD, or anxiety.

Forgiveness is a conscious and deliberate decision

We all have had the need to forgive, be forgiven, and more so have an idea of what is and isn’t forgiveness. The basic definition of forgiveness is the action or process of forgiving or being forgiven.

Forgiveness is a conscious, deliberate decision to release feelings of resentment or vengeance toward a person or group who has harmed you, regardless of whether they actually deserve your forgiveness. Experts who study or teach forgiveness make clear that when you forgive; you do not gloss over or deny the seriousness of an offense against you.

Forgiveness does not mean forgetting, nor does it mean condoning or excusing offenses.

Understanding forgiveness is important because when we holding resentment and anger, guilt and shame, impacts our general well being, happiness and our relationships.

And forgiveness is not for the other person – it’s not just about being altruistic. Those who hold anger and resentment are more likely to present psychological and organic illness. Forgiveness doesn’t have to follow the other person’s apology. Forgiveness is an internal event where you give up the need for an apology, a need to maintain anger, and perhaps disappointment. But also, you can’t affect the past. Forgiveness is an acceptance of what happened and asking yourself; "What can I do now?"

Think about the person you would like to rekindle a relationship with: What do you miss about them? Maybe laughing with them or sharing family traditions. You don’t have to wait for the other person to act. Why not you take the first step? Even if you were not the person who initially did the wrongdoing, you probably had some role in this. Could you be the first to apologize? Can you do it sincerely? 

First night's sleep

I would be the last person to link one-night stands with new research (Brown University) indicating that only half of our brain getting a good night's rest. More seriously, it turns out that our left brain seems to be more awake than the right side when we sleep in unfamiliar surroundings.

The finding, reported Thursday in the journal Current Biology, helps explain why people tend to feel tired after sleeping in a new place. And it suggests people have something in common with birds and sea mammals, which frequently put half their brain to sleep while the other half remains on guard.

Sleep researchers discovered the "first-night effect" decades ago, when they began studying people in sleep labs. The first night in a lab, a person's sleep is usually so bad that researchers simply toss out any data they collect.

The team measured something called slow-wave activity, which appears during deep sleep. And they found that during a student's first night in the lab, slow wave activity was greater in certain areas of the right hemisphere than in the corresponding areas of the left hemisphere. After the first night, though, the difference went away.

It’s possible that this is a survival trait - when we're sleeping in a new environment and we don't know how many predators are around. It would make sense to keep half the brain more alert and more responsive to bumps in the night.

The research is indicating that this brain response is involuntary and there's nothing people can do to prevent it.

Moving toward suicide test

According to a small study by researchers at Johns Hopkins University in Baltimore, Maryland and published in The American Journal of Psychiatry, they have identified a chemical change in a single gene that is common in people who attempt or commit suicide. The research has identified a gene mutation that could lead to a blood test to predict risk.

Such a test is years away from being widely available to the public. For now, researchers say they have found a chemical change in a single gene, called SKA2, which is linked to how the brain responds to stress hormones.

This gene "plays a significant role in turning what might otherwise be an unremarkable reaction to the strain of everyday life into suicidal thoughts and behaviours.” Researchers found it by examining brain samples from people who had killed themselves, and found that levels of SKA2 were significantly reduced compared to healthy people. 

They also tested blood samples from 325 people in a prevention study at JHU and found that changes in the gene could predict with 80 per cent certainty those who were experiencing suicidal thoughts or who had attempted suicide. Among certain groups, the accuracy of the test was even higher. "Those with more severe risk of suicide were predicted with 90 per cent accuracy," said the study. "In the youngest data set, they were able to identify with 96 per cent accuracy whether or not a participant had attempted suicide, based on blood test results."

The SKA2 gene works to inhibit negative thoughts and control impulsive actions. When there isn't enough of it, or it is altered, the brain releases abnormal levels of the stress hormone, cortisol. Previous studies have shown that people who try to kill themselves, or who commit suicide, have an abnormal cortisol release. More research is needed to determine if a blood test could predict suicide in a larger group of people.

Psychological Stress and Social Media Use

Whilst technology has been, by in large, seen a great enabler of productivity, efficacy and the backbone of current and future information bearing societies - technology has also proven to be a significant contributor of stress and anxiety.

More information is flowing into our lives; in many cases a decrement, requiring prompt attention, interrupting and distracting us from the activity on hand. Our insatiable need to track what friends and foes are doing and to monitor raises and falls in status is greater now than ever in the history of man’s existence. There is more social pressure now to disclose personal information and allow these technologies to takeover our lives, creating time and social pressures that put us at risk for the negative physical and psychological health effects that can result from stress.

Stress might come from maintaining a large network of Facebook friends, feeling jealous of their well-documented and well-appointed lives, the demands of replying to text messages, the addictive allure of photos of foods on our favourite social networks of choice.

A recent study (Pew Research Center Internet, Science & Tech, Jan 15, 2015) explored the relationship between a variety of digital technology uses and psychological stress. People were asked to respond to an established measure of stress - the Perceived Stress Scale (PSS). The PSS consists of ten questions and measures the degree to which individuals feel that their lives are overloaded, unpredictable and uncontrollable.

It turns out that the average American adult scored 10.2 out of 30 on the PSS. One of the starkest contrasts in the survey was between the level of reported stress experienced by men and women. On average, women report experiencing significantly higher levels of stress than men. Men reported stress levels that were 7% lower than for women. There are other demographic characteristics that are related to stress. On average, older adults, and those who are employed tend to have less stress.

In the survey, respondents were asked about their use of social networking sites. People were asked about the frequency with which they use different social media platforms, such as Facebook (used by 71% of internet users in this sample), Twitter (used by 18% of internet users), Instagram (17%) and LinkedIn (22%).

Given the popularity of Facebook, people were also asked very specific questions about users’ networks and what people do on that platform:

Number of friends (the average was 329),

Frequency of status updates (the average was 8 times per month)

Frequency of “Liking” other people’s content (the average was 34 times per month)

Frequency of commenting (the average was 22 times per month)

How often they send private messages (the average was 15 times per month)

Interestingly the frequency of internet and social media use has no direct relationship to stress in men. For women, the use of some technologies is tied to lower stress. For men, there is no relationship between psychological stress and frequent use of social media, mobile phones, or the internet more broadly. Men who use these technologies report similar levels of stress when compared with non-users.

For women, there is evidence that technology use is tied to modestly lower levels of stress. Specifically, the more pictures women share through their mobile phones, the more emails they send and receive, and the more frequently they use Twitter, the lower their reported stress. However, with the exception of Twitter, for the average person, the relationship between stress and these technologies is relatively small.

From this survey the researchers were not able to definitively determine why frequent uses of some technologies are related to lower levels of reported stress for women. Other studies have found that social sharing of both positive and negative events can be associated with emotional well-being and that women tend to share their emotional experiences with a wider range of people than do men.

Electronic health records, pyjama time and date night

According to a recent Clinical Psychiatry News article it seems physicians are beginning to call Electronic health record (HER) "Pajama time.” That’s the few hours physicians are spending every night finishing up their documentation, clearing out their in-box,”

University of Wisconsin researchers studying the impact of EHR systems on physicians’ workflow and lives looked at how often and when doctors were accessing their patients’ medical records. They found what many might think is obvious - doctors don’t have enough time in their days to finish their documentation, so they spend their evenings and weekends finishing up.

There is even a thing called “date night” which correlates with data showing this type of work being undertaken on Saturday nights. The same study “found that primary care physicians were spending 38 hours a month after hours doing data entry work.

At a session held in conjunction with the annual meeting of the Healthcare Information and Management Systems Society, Dr. Sinsky spoke about how electronic health records have not lived up to their promise of helping streamline patient care and instead have added hours and headaches to most physicians’ days. Here are a few of the reasons for this additional work.

1. It takes 33 clicks to order and record a flu shot. And in the emergency room, it takes 4,000 clicks to get through the day for a 10-hour shift.” Studies have shown that physicians are spending 44% of their day doing data entry work, [but] 28% of the day with their patient.”

2. Today’s EHRs have a workflow that doesn’t match how clinicians work.  Many clinicians are encountering these very rigid workflows that don’t meet the patient’s need and don’t meet the provider’s need.

3. Most EHRs lack a place for a photo of the patient and his or her family, and a place for the patient’s story, a deficiency that detracts from the value of the encounter.

4. Often, both a physician and a nurse or medical assistant need to add documentation to the EHR. Yet many systems are set up such that each party must log in, then log out, before another can contribute. 

496

We’re are all influenced by numbers psychology. The most basic is the notion of size. Our tendency to infer larger sizes or more of something from larger numbers. To downplay a 30-day service penalty, therefore, simply referring to it as a one-month suspension might help. Conversely, bigger numbers are used to convey increases in nutritional benefits (1,000 milligrams of fiber, not one gram) or mobile phone talk time (660 minutes, not 11 hours) to make us feel as though we are getting better deals.

But numbers are much more than that. There are a lot of important numbers out there. Some, like 42 had become popular among fans of the comic science fiction genre. You might recall in the radio series and the Adams’ first novel, a group of hyper-intelligent pan-dimensional beings demand to learn the Answer to the Ultimate Question of Life, The Universe, and Everything from the supercomputer, Deep Thought, specially built for this purpose. It takes Deep Thought 7½ million years to compute and check the answer, which turns out to be 42. Deep Thought points out that the answer seems meaningless because the beings who instructed it never actually knew what the Question was.

Later Adams was asked why he chose the number 42. Many theories were proposed, including that 42 is 101010 in binary code, that light refracts through a water surface by 42 degrees to create a rainbow, that light requires 10⁻⁴² seconds to cross the diameter of a proton. Adams rejected them all. In November 1993, he said “It was a joke. It had to be a number, an ordinary, smallish number, and I chose that one. Binary representations, base thirteen, Tibetan monks are all complete nonsense. I sat at my desk, stared into the garden and thought 42 will do; I typed it out. End of story.”

So I was saying there are many number of significance. Sure your girlfriend’s number is probably most important, but there are numbers and then there are numbers. Some numbers define our very existence. Some of these may well define the very workings of the universe. Consider for example Avogadro's number. This is the number of atoms in 12 grams of carbon, and is approximately six followed by 23 zeroes. The number of atoms can also be calculated using Avogadro's Constant (6.02214179×10²³) / one mole of substance.

Then there is Planck's constant. The universe packages energy in finite multiples of a smallest amount, much as the atomic theory proclaims that the universe packages matter in finite multiples of atoms. These small packages of energy are known as quanta, and Planck's constant, abbreviated h, tells us the size of these packages. The fundamental constant, equal to the energy of a quantum of electromagnetic radiation divided by its frequency, with a value of 6.626 × 10⁻³⁴ joules.

When we turn our attention to the history of the universe; There are really only two possibilities for the universe: Either it has always been here, or it had a beginning. It turns out that the universe is expanding; everything is flying apart. The relationship between the speed at which a galaxy appears to be moving away and its distance from earth is given by Hubble's constant. The constant H is one of the important because it may be used to estimate the size and age of the Universe. The Hubble constant is given by H = v/d.

Other important numbers include Boltzmann's constant, Schwarzschild radius, Chandrasekhar limit, Omega, Absolute zero, the speed of light.

The granddaddy of numbers, in my opinion is 496. This is most notable for being a perfect number, and one of the earliest numbers to be recognized as such. As a perfect number, it is tied to the Mersenne prime 31 2⁵ − 1, with 2⁴ (2⁵ − 1) yielding 496. Also related to its being a perfect number, 496 is a harmonic divisor number, since the number of proper divisors of 496 divided by the sum of the reciprocals of its divisors, 1, 2, 4, 8, 16, 31, 62, 124, 248 and 496, (the harmonic mean), yields an integer, 5 in this case. In 1984, Green and Schwarz realized that one of the necessary conditions for a superstring theory to make sense is that the dimension of the gauge group of type I string theory must be 496. Their discovery started the first superstring revolution.